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The Aging Process in Industrial Employees
The Aging Process in Industrial Employees HAROLD H.
STEI~BERG,
M.D.*
AGING in industry refers to a dynamic process which occurs in workers during their productive life. Since educational opportunities are now more readily available to many young persons, the age at which they begin to do organized work is often delayed to the age of 20 or thereafter. Their productive period ends at approximately age 70. With advances in medicine years have been added to life in the past half century, but the addition of life to years, a highly desirable goal, has not yet been achieved to any measurable extent. Although this has been accepted as a desirable incentive for the older individual, it seems even more important to retain it as a working objective during the entire life span. As a rule, it is true that one must work to live. The physician is aware of the fact that living consists of something more than satisfaction of a complex number of physiologic processes in order to survive. It is probably more in keeping with what Emerson thought when he said, "The high prize of life, the crowning fortune of a man, is to be born with a bias to some pursuit which finds him employment and happiness." In our culture, if we add to that a rewarding family relationship and the ability to participate as a recognized member of an identifiable group either at work or in a community activity, then one begins to approach the realm of successful living. In living there is constant aging. In both animate and inanimate objects, constant use will produce some deterioration. The rate will depend first on the innate character of the person or thing to resist wear and tear, secondly on the ability to respond to processes of repair, and thirdly on the effect of care in preventing deterioration. From a medical standpoint, we were first concerned with the identification and treatment of disease. This was followed by the important era of prevention of disease. In our own years of practice there have
* Associate in Medicine, Northwestern University Medical School; Assistant Medical Director, International Harvester Company, Chicago. 21
22
H arold H. Steinberg
become available the most effective drugs and auxiliary procedures in treatment ever known to medical science. The result of all of these advances has been a substantial increase in the life span of all persons born after the turn of the twentieth century. Because of this situation, physicians must become concerned with an important and practical aspect of medical practice, namely, the conservation of health. When we speak of a healthy individual we mean a state of physical and mental well-being, not merely the absence of disease or infirmity. The problem of aging in industry is, then, to observe what happens to people who, early in adult life, have begun to live and work in a society and culture largely dominated by industrial organization. What is the role of the physician during their process of aging? Early the process proceeds at a relatively slow pace, and there are few obvious characteristics of the aging process. Although there may be periods of disability from sickness or accident, these are generally not prolonged. Their effect on productivity, on the earning capacity of the individual, and on his sustained feeling of comfort, are usually not significant. Later, in the middle years of life, from the ages of 40 to 60, one sees more frequent signs of normal aging. Yet during these years the individual is able to participate quite effectively in normal activities of work and play which we categorize simply as enjoyable living. More surprisingly, even beyond the age of 60 a large majority of men and women seem to be able to continue in sustained and useful employment. Yet in all of these groups when considering individuals, the process of aging may proceed at an accelerated or unpredictable rate, causing frequent periods of ill health, reduced work capacity, or disability. It is in this group of people that one observes the breakdown in normal function of the individual. In terms of physiology this may be related to either lack of fulfillment or balance of physiologic, psychologic or social needs. Even in the so-called healthy worker the relative balance of these needs should concern all of us in the practice of medicine. In industry the physician has the fortunate and unique opportunity of observing relatively healthy individuals for the most part. His important role, therefore, relative to the aging process, is to promote those activities which will allow senescence to proceed as normally as is feasible. Let us consider the various procedures that promote this desirable goal. PLACEMENT OF THE WORKER
The industrial establishment that has inaugurated a medical program has indicated an intelligent attitude on the part of management to conserve its most valuable resource, human intellect and productivity. The employment department is alerted by management to the need for workers for specific jobs. An effective approach on the part of employment personnel is to appraise and classify specific jobs on the basis of
The Aging Process in Industrial Employees
23
their physical, emotional and environmental demands. After this information has been obtained, classified recruitment of needed workers is undertaken. As the applicant appears at the Medical Department for his examination the physician, with the simple job classification information before him, considers the suitability of the individual for the job on the basis of his findings on physical examination, evaluating the demands of the specific work for which the applicant is being examined. The medical goal of the preplacement examination is the placement of workers in jobs in which they will be effective. The elimination of the term "pre-employment examination" indicates that the medical examination is not a screening procedure in which only the healthiest of the group are selected. For the most part, this first contact with the doctor is the closest and most meaningful procedure in the new employee's relationship with the employer. A thoughtful human approach, a careful physical examination, performed in clean attractive surroundings, is a positive force for the beginning of a "healthy" employee-employer relationship. This is the first episode in a series of events and attitudes which can make the Medical Department a potent force in the important area of employee relations. Effective prep la cement laboratory procedures usually include a chest x-ray, urinalysis and blood serology. More recently some physicians have advocated hematocrit and hemoglobin determinations. Accurate testing of vision and hearing are replacing crude and uncritical methods previously in use. Applicants are classified into several categories related to the health conservation program. Class A applicants have no significant defects and the designation carries approval of placement in any type of work. The Class B applicant is onc who has a significant but correctable defect. It is in this group that the physician can encourage and initiate the program of health maintenance. The Class C applicant is acceptable for a limited type of work because of a static defect. He may be a partially or totally blind person or a handicapped worker. In properly selected jobs such persons can do useful work. They usually are not transferred to other types of work without medical approval. The Class D applicant is one who is not acceptable because it is felt that employment at the time would be injurious to his health or would be detrimental to the health of fellow employees. The person with active tuberculosis or other communicable disease, the uncontrolled diabetic, or the person in frank heart failure or with far advanced heart disease falls into this category. While a Class D applicant may be temporarily unacceptable for work, effective medical treatment may restore him to an employable status. If the attitudes of the Medical Department are oriented to health conservation, then all categories of employees will interest the industrial physician. The healthy Class A employee will be given information regarding nutrition, acceptable weight standards, and simple factual
Harold~H.
Steinberg
information relating to understanding of disease processes. More recently, workers have become interested in healthy emotional attitudes and the relationships of emotional factors to the production of symptoms and disease. The Class B employee is given all of this information, but in addition he is encouraged to have a hernia corrected, perhaps, or to receive treatment for varicose veins, usually under the direction of his own physician. He may be referred for dental care, for correction of vision or hearing, or for diagnosis and treatment of gastrointestinal complaints. The important role of the industrial physician is that of follow-up on his recommendations. This requires tact and intelligence. The Class C applicant is placed in a job compatible with his physical capacities. The Class D applicant needs immediate medical care. It is poor medical practice to reject an individual for employment without giving him justifiable medical reasons for his unacceptability for work. For example, the person with active tuberculosis might be referred to his own physician, or where there is none, to a community tuberculosis control unit. Yet, at the same time the importance of chest x-rays for his family and close contacts can be stressed. Even more important is the advice that early and effective treatment will restore health compatible with active employment. THE INDUSTRIAL ENVIRONMENT
Undesirable conditions in the industrial environment may insidiously affect the health of the worker. Exposure to harmful concentrations of toxic substances may produce significant disabling occupational disease. Excessive noise, poor illumination, faulty ventilation, or working at excessively low or high temperatures may be detrimental to the worker's health. Suitable sanitation, proper washing and locker room facilities, and adequate housing are all necessary in providing a satisfactory work place. Auxiliary measures, such as a general safety program, will help prevent industrial accidents. They should include training in safe performance of the job, proper safeguarding of machinery, and the use of personal safety equipment such as safety glasses and shoes, and protective clothing. PERIODIC PHYSICAL EXAMINATION AND HEALTH CONSULTATIONj
The employee's attitude toward the Medical Department is the most important single factor in determining the success or failure of the entire health conservation program. Employees will not participate in such a program unless they are convinced that the examination is worthwhile and the doctors are objectively interested in employee health. Nothing can be as disconcerting to an employee as to receive a cursory, disinterested physical examination. A sympathetic, interested attitude
The Aging Process in Industrial Employees
25
on the part of the physician can be of invaluable benefit in health consultation, and a careful, thorough physical examination can be a most effective procedure in a program of health maintenance. Dr. W. F. King, former Director of the Division of Adult Hygiene and Geriatrics of the Indiana State Board of Health, has said: "A physical examination should be more than an inspection, more than a determination of the presence or absence of disease. It should be, in fact, a health consultation between the individual and his physician in which the patient and the doctor talk over and study all matters concerning the health of the patient. It should be a health consultation in every meaning of the word. This means that both the physician and patient should not only be interested, but should make whatever effort is necessary to obtain a true health inventory of the patient-a correct measure of the ability of the patient to stand up under the strain of physical and mental exertion, and to detect any beginning functional or organic change in order to guard, as far as possible, against damaging change. Pediatricians have shown that apparently healthy and well babies can be made healthier and stronger, and thus be better fitted to meet the demands of adult life. Constructive medical guidance and health supervision applied to adults throughout the critical years of maturity should make apparently well men and women healthier and better prepared to add useful happy life to added years."!
There has been a great deal of discussion as to which accomplishes more in the realm of health maintenance, the frequent medical interview where the individual is free to come to the doctor with early symptoms, or the performance of a careful periodic physical examination. Actually these procedures supplement one another and are invaluable in retarding the aging process. One cannot describe these procedures in detail, but essentially they revolve around the performance of adequate physical examinations, the diligent use of laboratory procedures, and the intelligent evaluation of findings in the "total person" that is being examined. Health consultation should be encouraged and the medical findings and advice should be in terms that the layman can understand. Adequate medical care can be exceedingly fruitful to employee and employer alike in increasing productivity, reducing absenteeism and generally promoting more satisfactory employer-employee relationships. The medical profession and its allied disciplines may be overlooking an unusual opportunity to observe and study the process of aging as it occurs in the healthy person. In industry a large segment of the adult population is actively employed earning a livelihood. What are some of the indices of biological change which indicate departure from the normal aging process? Are there measurable changes indicative of abnormal or accelerated aging? Perhaps we could determine the additive effect of combined stress situations as they are produced by physiologic and psychologic stimuli. Industrial groups offer a fertile field for clinical investigation of the borderline zone between health and sickness. It is in this area that great strides can be made in health conservation.
26
H aroid H. Steinberg EMOTIONAL ASPECTS IN THE HEALTH NEEDS OF INDUSTRIAL WORKERS
One of the problems of an industrial culture is to provide some way to satisfy the emotional needs of the individual as he attempts to adapt to his environment. The needs of the individual to earn a livelihood and to assume the role of head of the family are partially met by the financial rewards of his labor. Other needs, which are for the most part unconscious, are as yet not clearly understood and are not completely satisfied by the man's job. Motivation studies may reveal what the worker really wants from his job. Some psychiatrists are of the belief that some of the unconscious, aggressive and even hostile drives of the normal person may be channeled into creative work. Such needs may not be met adequately on assembly line production. It would seem that the average worker expects to get certain basic satisfactions from his work. 2 He wants recognition for achievement, performance and loyalty. He wants to feel that he is needed and wanted, and to feel secure in his job. Many procedures have been initiated in industry that recognize emotional needs and stresses as they arise in industrial situations. Some industries have instituted nondirective counselling programs for workers, the early results of which have been encouraging. In other industries mental health conservation has included supervisor and foreman training in human relations, psychiatric or psychologic counselling before promotion and transfer, and employee attitude surveys. THE OLDER WORKER
In a discussion of aging in industry some persons would confine their observations to the older worker in whom aging has produced noticeable change. Old age is difficult to define. Some people are sick in mind and body at the age of 50, others vigorous and alert at the age of 85. The man of 70 is young to the man of 90 and old to the youth of 20, who is still a youngster to his grandmother, but old in the eyes of children. 3 The story is told of Supreme Court Justice Oliver Wendell Holmes, who lived to be 94, and who had a zest for living which he never lost. On one occasion, noticing a woman's slim ankle, he remarked with a sigh, "Ah, what I'd give to be 70 again!"3 In identifying the people we are discussing, we will arbitrarily designate the older worker as one who is 65 years old or more. Approximately 40 per cent of the men in this group are working full or part time. Employment is the largest source of their income. The percentage of older people actively employed has tended to fall since 1900 except for the two World War periods. As recently as 1870 about 80 per cent of all men over 65 were working actively, principally on farms. With movement of population to urban centers the proportion dropped to 65 per cent in 1900. During the second World War 50 per cent of older males were employed.
The Aging Process in Industrial Employees
27
The highest numbers of older persons are employed a;:; farmers, miners, railroad men, at retail sales and in self-employment. There is decreasing total employment in all of these industries except for retailing. On January 1, 1953 the Census Bureau estimated that there were 13,400,000 people 65 years of age or more, representing 9 per cent of our total population. It has been estimated that by 1975 the number will be 20,000,000. Programs which encourage employment and intelligent work placement of older persons are healthy for the economy of the nation. Studies have shown, both from phy;:;iologic and p;:;ychologic viewpoints, that active employment is an important factor in maintaining satisfactory health in this group. The real limitation on employment of the older worker is the decrease in capacity to perform various types of work. It is the exceptional person who can do consistently hard physical work at the age of 65. This is even more evident in more advanced years. However, many physicians in industry have observed that older persons with experience and skill can minimize the amount of physical effort expended, even in the heavy jobs of industry. This has certainly been our experience. In the realm of the skilled worker at the machine, the toolmaker, pattern worker, carpenter, clerical worker, supervisor and executive, older persons do at least as well and often better than younger ones. Consultation between the industrial physician and the supervisor or department head often leads to proper placement, or else transfer, of the older worker to a job consistent with his capacity to perform. Another barrier to employment of older workers is the belief that they are subject to more illness than other groups. Their disability rate is believed to be about two and one-half times that of the rest of the employed group. The incidence of chronic disease is believed to be about four times that of the population as a whole. 4 Let mc, however, cite the experience of a large company which manufactures farm implements. Their plant wa;:; originally established more than 100 years ago. Its employment records have been stable, with a large percentage of employees in service for 30 to 40 years or more. In this group 84 persons more than 64 years of age were employed as of January 1955. Five hundred and sixty-two employees, or approximately 15 per cent of the total plant population (Table 1), are more than 60 years of age. The distribution of employees more than 64 years old in individual age groups is shown in Table 2. They are employed at various jobs within the plant, many of which require considerable physical effort. More than 21 employees in this group, about onefourth of the total, had not lost a single day either from illness or accident since the age of 60 (Table 3). In evaluating disability rates in this group of workers, one finds that the absenteeism rates compare favorably with younger workers less than 30 years of age. In evaluating these ;:;tatistics onc must recognize that only the hardier
H arold H. Steinberg
28 Table 1
NUMBER OF EMPLOYEES BY AGE DISTRIBUTION
AGE
Under 60 years 60 to 64 years 64 years and over TOTAL
NUMBER
PER CENT OF TOTAL
3203 478
85.1 12.7 2.2 100.0%
84
3765
Table 2 DISTRIBUTION BY AGE OF EMPLOYEES
AGE
64 years 65 " 66 " 67 " 68 " 70 TOTAL
64
YEARS OLD OR OLDER
NUMBER
PER CENT OF TOTAL
46 22 8 6 1 1 84
54.8 26.2 9.5 7.1 1.2 1.2 100.0%
Table 3 N UMBER AND PERCENTAGE WITHOUT DISABILITY AFTER Am] 64 YEARS OLD OR MORE
AGE
64 years 65 " 66 " 67 " 68 " 70 " TOTAL
NUMBER
60
IN
84
EMPLOYEES
PER CENT OF TOTAL
11 7 3
13.1 8.3 3.6
21
25.0%
individuals are represented. Those who have retired at an earlier age because of illness or injury are not considered. Sickness disability rates might be different with widespread employment of older persons, but not necessarily unfavorable to the older worker. The industrial physician meets another challenge in trying to keep this group of people employable. Employers- have frequently stated that older workers are steady, stable and conscientious, and that they perform in a more workmanlike manner than younger workers.
The Aging Process in Industrial Employees
29
HEALTH PROGRAMS FOR OLDER WORKERS
A positive program of health maintenance must be based on physiologic and psychologic needs, as well as on socio-economic factors as they affect the health of older employees. In recent years, health needs of the elderly individual have been too closely identified with the needs of the chronically ill. While it is true that chronic illness in old age is more common than in earlier life, chronic illness is not confined to the old, nor is it true that age necessarily brings chronic disease. The identification of chronic illness with age is unfortunate in that it obscures other important health needs of the older person. Stieglitz 6 points out that in young persons the cause of disease comes from outside. In contrast, the so-called degenerative diseases usually come from causes that are endogenous, obscure, cumulative and multiple, with many superimposed factors. Their origin is far in the past. He emphasizes that the physician must not forget the effect of past influences which make old people different from each other, these differences increasing with age. Activities in the field of health conservation must take into account the fact that many adaptive mechanisms, both physiologic and psychologic, have already been well established in the individual. Often they should not be interrupted by overzealous and ineffective therapeutic procedures. There is increasing evidence of higher incidence of tuberculosis in older persons. This trend will probably continue as the life span is increased. 7 Tuberculosis usually presents itself as a subtle disease in the elderly. It is slowly progressive and chronic, with few symptoms, and for these reasons the older patient may be a significant source of infection. The disease often is first discovered as a result of an x-ray film of the chest taken in a periodic industrial health examination. Malnutrition and vitamin deficiency are relatively common in older workers. They may be caused by poor absorption of food by an atrophic gastric mucosa, or by inadequate and improper food intake. Lessened activity of advancing years may lower caloric requirements, but it does not reduce the necessity for a balanced diet. Overeating and obesity with frequently associated degenerative vascular changes are other health hazards of older persons. Pearlman has advocated six major health rules for aging people. 8 These are: a thorough physical examination every six to twelve months; an adequate diet; regular exercise; interests outside of job and home; avoidance of overconcern about health; and wise planning for actual retirement. It is advisable that workers over 60 be encouraged to seek health consultation early when symptoms appear. When they do, their physicians should supply informative medical material, written or oral. The older person should feel secure about his health rather than fearful and
so
Harold H. Steinberg
anxious about morbid and disabling disease. Such material requires careful selection and presentation. EMOTIONAL PROBLEMS OF THE OLDER WORKER
Weinberg lD presents this problem well when he says: "Broadly speaking, the problenul of senescence arise intrinsically from the threat of organ destruction, and extrim;ically from socio-economic factors. With the decrement in personal, physical and emotional assets the older person finds very little support or supplementation from the world that he lives in. Our social and economic systems add little to the comfort of the aged, but do a great deal to further his apprehensions. "Work may give the older worker status and strength, for being employed makes him feel young within himself and, therefore, buffers the threat of being old and unproductive .... 'Vhen one is young one's appearance may be sufficient to make one attractive and sought after. Once the aging process alters our appearance, the greying, wrinkled balding facade must be augmented by other meaningful factors to help keep us in the eyes of human beings, and avoid isolation. The mere fact that a man works makes the community of people about him regard him as still capable, youthful and virile. "Then there are people to whom work has the meaning of social interchange. They can only relate themselves to others through their work. Work becomes their medium of communication and once removed from its milieu they are lost. Obviously for these people to be removed from a job may mean total social isolation and thereby deterioration." NEEDS OF THE OLDER WORKER FOR MEDICAL CARE
As long as an older person is working actively, he can participate in the health and welfare programs provided for all employees. Hospitalization insurance, sickness benefits, group life insurance and medical care programs may be available. For the most part these benefits are terminated when a person stops working. But that is the time when such benefits are needed most. The Committee on Aging and Geriatrics of the Federal Security Agency stated in 19.524 that 36 per cent of all people between the ages of 65 and 69, 25 per cent of those between 70 and 74, and 15 per cent of those 75 years of age or older owned some kind of hospital insurance. At present the trend is to provide hospital and surgical benefits for retired workers. Policies can be written by commercial carriers, or through Blue Cross or Blue Shield. By placing some restriction on the maximum benefits a retired employee may receive under group insurance, the cost of the plan can be held down and yet give the pensioner some protection. A 1954 survey showed that approximately 40 per cent of 327 companies of varied size provide hospital benefits for retired employees. ID RETIREMENT OF EMPLOYEES
The problem of when and how to retire employees is a major concern in many quarters. These include leaders of management and labor,
The Aging Process in Industrial Employees
31
schools of business administration and industrial relations, sociologists, and industrial physicians, psychiatrists and psychologists. The problem is complicated further by collective bargaining agreements and fixed management policies. More often than not no specific policy relating to retirement procedures or counselling exists. There are three main retirement policies in existence :10 1. Discretionary retirement, under which the company permits the employee to continue working with few or no restrictions. 2. Automatic retirement, under which the employee is automatically retired at a specified age unless he receives management approval to continue working. 3. Mandatory or compulsory retirement, under which an employee must retire at a given age, with few or no exceptions allowed. Flexible retirement policies permit retention of valuable employees. Individual decisions are possible, since persons do not reach retirement age at the same time. It lessens hardship for employees who might otherwise retire with inadequate benefits. The primary disadvantages of any flexible plan are that it may delay promotion of younger employees, create employee uncertainty about retirement, and present administrative problems in selective retirement. Mandatory retirement has the advantages of anticipation and planning for retirement by employees. It allows for promotion of younger employees in an orderly fashion, and it is easy to administer. Its greatest disadvantages are the difficulty of adjustment to obligatory retirement, and the financial burden assumed by retiring individual. A large number of retired employees with inadequate retirement benefits could handicap the general economy of the country. The attitude of employees toward retirement varies. People adjust well who have planned for retirement, have adequate financial resources, satisfactory health, and who have had continued interest in activities other than work for many years. But one of these attributes alone does not guarantee a successful adjustment. Work activities are for many employees a major form of social participation. Leaving other workers on the job causes social isolation after retirement. This situation may be temporary. It has been called "retirement shock." Counselling programs in preparation for retirement vary a great deal, but there is general agreement that counselling must be included if the program is to be successful. Yet as late as 1954, only 65 per cent of 327 .companies surveyed had initiated such programs. 10 Counselling regarding retirement may begin as soon as five years, or as late as a few months, before an employee retires. Many retirement programs concern themselves in great detail with the physical and emotional aspects of health in this age group. About three out of five workers find retirement to be a satisfying experience, whereas the other two out of five resist retirement and remain unhappy afterwards.
Harold H. Steinberg
32 SUMMARY
The process of aging in industry is best met by a consistent and sustained program of health conservation that begins with the first placement examination and continues throughout the entire span of years of employment. If properly carried out, such programs can result in increased productivity, more comfortable living, and lessened incidence of disabling disease and injury. Assuming that it is good business to have an effective medical program, small industries employing 100 persons or even fewer find it profitable to create health services. These services do not need to employ full-time personnel, but to be effective they must include all of the essential facets of an industrial health program. Studies should be conducted which give further consideration to all jobs at which the older worker can be comfortably and successfully employed. Many such employees have developed high degrees of skill and have had vast experience-attributes which can be used in many different kinds of work. It is not wise to allow a segment of the population, which within 25 years may become as large as 20,000,000 persons, to be unproductive and unemployed. The role of medicine in industry is health conservation. Tremendous strides have been made in preventing, diagnosing and treating disease. As a result, life has been prolonged and better opportunities to maintain health have been created. Health maintenance is an important role in the general field of medical care. This aspect of medical practice is exceedingly important in the work of the industrial physician. To all physicians it can be a rewarding and challenging experience. REFERENCES 1. King, W. F.: Health Guidance in Advancing Years. Proc. Institute of Geriatrics, Indiana University School of Medicine and Indiana State Board of Health, May 22, 1946. 2. U. S. Department of Health, Education and Welfare: It's Good Business to Know Your Men. Public Health Bulletin No. 379, 1954. l3. Pearlman, S. L.: The Physical Side of Aging. Industrial Relations Center, The University of Chicago, 1955. 4. Federal Security Agency, Committee on Aging and Geriatrics: Fact Book on Aging. U. S. Govt. Printing Office, 1952. 5. Hays, M.: Problems of Older Workers. Proceedings of a Conference, Janesville, Wisconsin, 1953. 6. Stieglitz, E. J.: Certain Aspects of Geriatric Medicine. Proc. Institute of Geriatrics, Indiana University School of Medicine and Indiana State Board of Health, May 22, 1946. 7. Myers, J. A.: Tuberculosis Among Persons over 50 Years of Age. Geriatrics 1: 27,1£)46. 8. Kuh, Clifford: Geriatrics in Industrial Medicine. Yale J. BioI. & Med. 19: 4 (March) 1947 9. Weinberg, J.: Mental Health Needs of the Aged. Community Project for the Aged, May 6, 1948. 10. National Industrial Conference Board, New York: Retirement of Employees; Studies in Personnel Policy, Conference Board Reports No. 148, 1955. 122 S. Michigan Avenue Chicago 3, Illinois
STEI~BERG,
M.D.*
AGING in industry refers to a dynamic process which occurs in workers during their productive life. Since educational opportunities are now more readily available to many young persons, the age at which they begin to do organized work is often delayed to the age of 20 or thereafter. Their productive period ends at approximately age 70. With advances in medicine years have been added to life in the past half century, but the addition of life to years, a highly desirable goal, has not yet been achieved to any measurable extent. Although this has been accepted as a desirable incentive for the older individual, it seems even more important to retain it as a working objective during the entire life span. As a rule, it is true that one must work to live. The physician is aware of the fact that living consists of something more than satisfaction of a complex number of physiologic processes in order to survive. It is probably more in keeping with what Emerson thought when he said, "The high prize of life, the crowning fortune of a man, is to be born with a bias to some pursuit which finds him employment and happiness." In our culture, if we add to that a rewarding family relationship and the ability to participate as a recognized member of an identifiable group either at work or in a community activity, then one begins to approach the realm of successful living. In living there is constant aging. In both animate and inanimate objects, constant use will produce some deterioration. The rate will depend first on the innate character of the person or thing to resist wear and tear, secondly on the ability to respond to processes of repair, and thirdly on the effect of care in preventing deterioration. From a medical standpoint, we were first concerned with the identification and treatment of disease. This was followed by the important era of prevention of disease. In our own years of practice there have
* Associate in Medicine, Northwestern University Medical School; Assistant Medical Director, International Harvester Company, Chicago. 21
22
H arold H. Steinberg
become available the most effective drugs and auxiliary procedures in treatment ever known to medical science. The result of all of these advances has been a substantial increase in the life span of all persons born after the turn of the twentieth century. Because of this situation, physicians must become concerned with an important and practical aspect of medical practice, namely, the conservation of health. When we speak of a healthy individual we mean a state of physical and mental well-being, not merely the absence of disease or infirmity. The problem of aging in industry is, then, to observe what happens to people who, early in adult life, have begun to live and work in a society and culture largely dominated by industrial organization. What is the role of the physician during their process of aging? Early the process proceeds at a relatively slow pace, and there are few obvious characteristics of the aging process. Although there may be periods of disability from sickness or accident, these are generally not prolonged. Their effect on productivity, on the earning capacity of the individual, and on his sustained feeling of comfort, are usually not significant. Later, in the middle years of life, from the ages of 40 to 60, one sees more frequent signs of normal aging. Yet during these years the individual is able to participate quite effectively in normal activities of work and play which we categorize simply as enjoyable living. More surprisingly, even beyond the age of 60 a large majority of men and women seem to be able to continue in sustained and useful employment. Yet in all of these groups when considering individuals, the process of aging may proceed at an accelerated or unpredictable rate, causing frequent periods of ill health, reduced work capacity, or disability. It is in this group of people that one observes the breakdown in normal function of the individual. In terms of physiology this may be related to either lack of fulfillment or balance of physiologic, psychologic or social needs. Even in the so-called healthy worker the relative balance of these needs should concern all of us in the practice of medicine. In industry the physician has the fortunate and unique opportunity of observing relatively healthy individuals for the most part. His important role, therefore, relative to the aging process, is to promote those activities which will allow senescence to proceed as normally as is feasible. Let us consider the various procedures that promote this desirable goal. PLACEMENT OF THE WORKER
The industrial establishment that has inaugurated a medical program has indicated an intelligent attitude on the part of management to conserve its most valuable resource, human intellect and productivity. The employment department is alerted by management to the need for workers for specific jobs. An effective approach on the part of employment personnel is to appraise and classify specific jobs on the basis of
The Aging Process in Industrial Employees
23
their physical, emotional and environmental demands. After this information has been obtained, classified recruitment of needed workers is undertaken. As the applicant appears at the Medical Department for his examination the physician, with the simple job classification information before him, considers the suitability of the individual for the job on the basis of his findings on physical examination, evaluating the demands of the specific work for which the applicant is being examined. The medical goal of the preplacement examination is the placement of workers in jobs in which they will be effective. The elimination of the term "pre-employment examination" indicates that the medical examination is not a screening procedure in which only the healthiest of the group are selected. For the most part, this first contact with the doctor is the closest and most meaningful procedure in the new employee's relationship with the employer. A thoughtful human approach, a careful physical examination, performed in clean attractive surroundings, is a positive force for the beginning of a "healthy" employee-employer relationship. This is the first episode in a series of events and attitudes which can make the Medical Department a potent force in the important area of employee relations. Effective prep la cement laboratory procedures usually include a chest x-ray, urinalysis and blood serology. More recently some physicians have advocated hematocrit and hemoglobin determinations. Accurate testing of vision and hearing are replacing crude and uncritical methods previously in use. Applicants are classified into several categories related to the health conservation program. Class A applicants have no significant defects and the designation carries approval of placement in any type of work. The Class B applicant is onc who has a significant but correctable defect. It is in this group that the physician can encourage and initiate the program of health maintenance. The Class C applicant is acceptable for a limited type of work because of a static defect. He may be a partially or totally blind person or a handicapped worker. In properly selected jobs such persons can do useful work. They usually are not transferred to other types of work without medical approval. The Class D applicant is one who is not acceptable because it is felt that employment at the time would be injurious to his health or would be detrimental to the health of fellow employees. The person with active tuberculosis or other communicable disease, the uncontrolled diabetic, or the person in frank heart failure or with far advanced heart disease falls into this category. While a Class D applicant may be temporarily unacceptable for work, effective medical treatment may restore him to an employable status. If the attitudes of the Medical Department are oriented to health conservation, then all categories of employees will interest the industrial physician. The healthy Class A employee will be given information regarding nutrition, acceptable weight standards, and simple factual
Harold~H.
Steinberg
information relating to understanding of disease processes. More recently, workers have become interested in healthy emotional attitudes and the relationships of emotional factors to the production of symptoms and disease. The Class B employee is given all of this information, but in addition he is encouraged to have a hernia corrected, perhaps, or to receive treatment for varicose veins, usually under the direction of his own physician. He may be referred for dental care, for correction of vision or hearing, or for diagnosis and treatment of gastrointestinal complaints. The important role of the industrial physician is that of follow-up on his recommendations. This requires tact and intelligence. The Class C applicant is placed in a job compatible with his physical capacities. The Class D applicant needs immediate medical care. It is poor medical practice to reject an individual for employment without giving him justifiable medical reasons for his unacceptability for work. For example, the person with active tuberculosis might be referred to his own physician, or where there is none, to a community tuberculosis control unit. Yet, at the same time the importance of chest x-rays for his family and close contacts can be stressed. Even more important is the advice that early and effective treatment will restore health compatible with active employment. THE INDUSTRIAL ENVIRONMENT
Undesirable conditions in the industrial environment may insidiously affect the health of the worker. Exposure to harmful concentrations of toxic substances may produce significant disabling occupational disease. Excessive noise, poor illumination, faulty ventilation, or working at excessively low or high temperatures may be detrimental to the worker's health. Suitable sanitation, proper washing and locker room facilities, and adequate housing are all necessary in providing a satisfactory work place. Auxiliary measures, such as a general safety program, will help prevent industrial accidents. They should include training in safe performance of the job, proper safeguarding of machinery, and the use of personal safety equipment such as safety glasses and shoes, and protective clothing. PERIODIC PHYSICAL EXAMINATION AND HEALTH CONSULTATIONj
The employee's attitude toward the Medical Department is the most important single factor in determining the success or failure of the entire health conservation program. Employees will not participate in such a program unless they are convinced that the examination is worthwhile and the doctors are objectively interested in employee health. Nothing can be as disconcerting to an employee as to receive a cursory, disinterested physical examination. A sympathetic, interested attitude
The Aging Process in Industrial Employees
25
on the part of the physician can be of invaluable benefit in health consultation, and a careful, thorough physical examination can be a most effective procedure in a program of health maintenance. Dr. W. F. King, former Director of the Division of Adult Hygiene and Geriatrics of the Indiana State Board of Health, has said: "A physical examination should be more than an inspection, more than a determination of the presence or absence of disease. It should be, in fact, a health consultation between the individual and his physician in which the patient and the doctor talk over and study all matters concerning the health of the patient. It should be a health consultation in every meaning of the word. This means that both the physician and patient should not only be interested, but should make whatever effort is necessary to obtain a true health inventory of the patient-a correct measure of the ability of the patient to stand up under the strain of physical and mental exertion, and to detect any beginning functional or organic change in order to guard, as far as possible, against damaging change. Pediatricians have shown that apparently healthy and well babies can be made healthier and stronger, and thus be better fitted to meet the demands of adult life. Constructive medical guidance and health supervision applied to adults throughout the critical years of maturity should make apparently well men and women healthier and better prepared to add useful happy life to added years."!
There has been a great deal of discussion as to which accomplishes more in the realm of health maintenance, the frequent medical interview where the individual is free to come to the doctor with early symptoms, or the performance of a careful periodic physical examination. Actually these procedures supplement one another and are invaluable in retarding the aging process. One cannot describe these procedures in detail, but essentially they revolve around the performance of adequate physical examinations, the diligent use of laboratory procedures, and the intelligent evaluation of findings in the "total person" that is being examined. Health consultation should be encouraged and the medical findings and advice should be in terms that the layman can understand. Adequate medical care can be exceedingly fruitful to employee and employer alike in increasing productivity, reducing absenteeism and generally promoting more satisfactory employer-employee relationships. The medical profession and its allied disciplines may be overlooking an unusual opportunity to observe and study the process of aging as it occurs in the healthy person. In industry a large segment of the adult population is actively employed earning a livelihood. What are some of the indices of biological change which indicate departure from the normal aging process? Are there measurable changes indicative of abnormal or accelerated aging? Perhaps we could determine the additive effect of combined stress situations as they are produced by physiologic and psychologic stimuli. Industrial groups offer a fertile field for clinical investigation of the borderline zone between health and sickness. It is in this area that great strides can be made in health conservation.
26
H aroid H. Steinberg EMOTIONAL ASPECTS IN THE HEALTH NEEDS OF INDUSTRIAL WORKERS
One of the problems of an industrial culture is to provide some way to satisfy the emotional needs of the individual as he attempts to adapt to his environment. The needs of the individual to earn a livelihood and to assume the role of head of the family are partially met by the financial rewards of his labor. Other needs, which are for the most part unconscious, are as yet not clearly understood and are not completely satisfied by the man's job. Motivation studies may reveal what the worker really wants from his job. Some psychiatrists are of the belief that some of the unconscious, aggressive and even hostile drives of the normal person may be channeled into creative work. Such needs may not be met adequately on assembly line production. It would seem that the average worker expects to get certain basic satisfactions from his work. 2 He wants recognition for achievement, performance and loyalty. He wants to feel that he is needed and wanted, and to feel secure in his job. Many procedures have been initiated in industry that recognize emotional needs and stresses as they arise in industrial situations. Some industries have instituted nondirective counselling programs for workers, the early results of which have been encouraging. In other industries mental health conservation has included supervisor and foreman training in human relations, psychiatric or psychologic counselling before promotion and transfer, and employee attitude surveys. THE OLDER WORKER
In a discussion of aging in industry some persons would confine their observations to the older worker in whom aging has produced noticeable change. Old age is difficult to define. Some people are sick in mind and body at the age of 50, others vigorous and alert at the age of 85. The man of 70 is young to the man of 90 and old to the youth of 20, who is still a youngster to his grandmother, but old in the eyes of children. 3 The story is told of Supreme Court Justice Oliver Wendell Holmes, who lived to be 94, and who had a zest for living which he never lost. On one occasion, noticing a woman's slim ankle, he remarked with a sigh, "Ah, what I'd give to be 70 again!"3 In identifying the people we are discussing, we will arbitrarily designate the older worker as one who is 65 years old or more. Approximately 40 per cent of the men in this group are working full or part time. Employment is the largest source of their income. The percentage of older people actively employed has tended to fall since 1900 except for the two World War periods. As recently as 1870 about 80 per cent of all men over 65 were working actively, principally on farms. With movement of population to urban centers the proportion dropped to 65 per cent in 1900. During the second World War 50 per cent of older males were employed.
The Aging Process in Industrial Employees
27
The highest numbers of older persons are employed a;:; farmers, miners, railroad men, at retail sales and in self-employment. There is decreasing total employment in all of these industries except for retailing. On January 1, 1953 the Census Bureau estimated that there were 13,400,000 people 65 years of age or more, representing 9 per cent of our total population. It has been estimated that by 1975 the number will be 20,000,000. Programs which encourage employment and intelligent work placement of older persons are healthy for the economy of the nation. Studies have shown, both from phy;:;iologic and p;:;ychologic viewpoints, that active employment is an important factor in maintaining satisfactory health in this group. The real limitation on employment of the older worker is the decrease in capacity to perform various types of work. It is the exceptional person who can do consistently hard physical work at the age of 65. This is even more evident in more advanced years. However, many physicians in industry have observed that older persons with experience and skill can minimize the amount of physical effort expended, even in the heavy jobs of industry. This has certainly been our experience. In the realm of the skilled worker at the machine, the toolmaker, pattern worker, carpenter, clerical worker, supervisor and executive, older persons do at least as well and often better than younger ones. Consultation between the industrial physician and the supervisor or department head often leads to proper placement, or else transfer, of the older worker to a job consistent with his capacity to perform. Another barrier to employment of older workers is the belief that they are subject to more illness than other groups. Their disability rate is believed to be about two and one-half times that of the rest of the employed group. The incidence of chronic disease is believed to be about four times that of the population as a whole. 4 Let mc, however, cite the experience of a large company which manufactures farm implements. Their plant wa;:; originally established more than 100 years ago. Its employment records have been stable, with a large percentage of employees in service for 30 to 40 years or more. In this group 84 persons more than 64 years of age were employed as of January 1955. Five hundred and sixty-two employees, or approximately 15 per cent of the total plant population (Table 1), are more than 60 years of age. The distribution of employees more than 64 years old in individual age groups is shown in Table 2. They are employed at various jobs within the plant, many of which require considerable physical effort. More than 21 employees in this group, about onefourth of the total, had not lost a single day either from illness or accident since the age of 60 (Table 3). In evaluating disability rates in this group of workers, one finds that the absenteeism rates compare favorably with younger workers less than 30 years of age. In evaluating these ;:;tatistics onc must recognize that only the hardier
H arold H. Steinberg
28 Table 1
NUMBER OF EMPLOYEES BY AGE DISTRIBUTION
AGE
Under 60 years 60 to 64 years 64 years and over TOTAL
NUMBER
PER CENT OF TOTAL
3203 478
85.1 12.7 2.2 100.0%
84
3765
Table 2 DISTRIBUTION BY AGE OF EMPLOYEES
AGE
64 years 65 " 66 " 67 " 68 " 70 TOTAL
64
YEARS OLD OR OLDER
NUMBER
PER CENT OF TOTAL
46 22 8 6 1 1 84
54.8 26.2 9.5 7.1 1.2 1.2 100.0%
Table 3 N UMBER AND PERCENTAGE WITHOUT DISABILITY AFTER Am] 64 YEARS OLD OR MORE
AGE
64 years 65 " 66 " 67 " 68 " 70 " TOTAL
NUMBER
60
IN
84
EMPLOYEES
PER CENT OF TOTAL
11 7 3
13.1 8.3 3.6
21
25.0%
individuals are represented. Those who have retired at an earlier age because of illness or injury are not considered. Sickness disability rates might be different with widespread employment of older persons, but not necessarily unfavorable to the older worker. The industrial physician meets another challenge in trying to keep this group of people employable. Employers- have frequently stated that older workers are steady, stable and conscientious, and that they perform in a more workmanlike manner than younger workers.
The Aging Process in Industrial Employees
29
HEALTH PROGRAMS FOR OLDER WORKERS
A positive program of health maintenance must be based on physiologic and psychologic needs, as well as on socio-economic factors as they affect the health of older employees. In recent years, health needs of the elderly individual have been too closely identified with the needs of the chronically ill. While it is true that chronic illness in old age is more common than in earlier life, chronic illness is not confined to the old, nor is it true that age necessarily brings chronic disease. The identification of chronic illness with age is unfortunate in that it obscures other important health needs of the older person. Stieglitz 6 points out that in young persons the cause of disease comes from outside. In contrast, the so-called degenerative diseases usually come from causes that are endogenous, obscure, cumulative and multiple, with many superimposed factors. Their origin is far in the past. He emphasizes that the physician must not forget the effect of past influences which make old people different from each other, these differences increasing with age. Activities in the field of health conservation must take into account the fact that many adaptive mechanisms, both physiologic and psychologic, have already been well established in the individual. Often they should not be interrupted by overzealous and ineffective therapeutic procedures. There is increasing evidence of higher incidence of tuberculosis in older persons. This trend will probably continue as the life span is increased. 7 Tuberculosis usually presents itself as a subtle disease in the elderly. It is slowly progressive and chronic, with few symptoms, and for these reasons the older patient may be a significant source of infection. The disease often is first discovered as a result of an x-ray film of the chest taken in a periodic industrial health examination. Malnutrition and vitamin deficiency are relatively common in older workers. They may be caused by poor absorption of food by an atrophic gastric mucosa, or by inadequate and improper food intake. Lessened activity of advancing years may lower caloric requirements, but it does not reduce the necessity for a balanced diet. Overeating and obesity with frequently associated degenerative vascular changes are other health hazards of older persons. Pearlman has advocated six major health rules for aging people. 8 These are: a thorough physical examination every six to twelve months; an adequate diet; regular exercise; interests outside of job and home; avoidance of overconcern about health; and wise planning for actual retirement. It is advisable that workers over 60 be encouraged to seek health consultation early when symptoms appear. When they do, their physicians should supply informative medical material, written or oral. The older person should feel secure about his health rather than fearful and
so
Harold H. Steinberg
anxious about morbid and disabling disease. Such material requires careful selection and presentation. EMOTIONAL PROBLEMS OF THE OLDER WORKER
Weinberg lD presents this problem well when he says: "Broadly speaking, the problenul of senescence arise intrinsically from the threat of organ destruction, and extrim;ically from socio-economic factors. With the decrement in personal, physical and emotional assets the older person finds very little support or supplementation from the world that he lives in. Our social and economic systems add little to the comfort of the aged, but do a great deal to further his apprehensions. "Work may give the older worker status and strength, for being employed makes him feel young within himself and, therefore, buffers the threat of being old and unproductive .... 'Vhen one is young one's appearance may be sufficient to make one attractive and sought after. Once the aging process alters our appearance, the greying, wrinkled balding facade must be augmented by other meaningful factors to help keep us in the eyes of human beings, and avoid isolation. The mere fact that a man works makes the community of people about him regard him as still capable, youthful and virile. "Then there are people to whom work has the meaning of social interchange. They can only relate themselves to others through their work. Work becomes their medium of communication and once removed from its milieu they are lost. Obviously for these people to be removed from a job may mean total social isolation and thereby deterioration." NEEDS OF THE OLDER WORKER FOR MEDICAL CARE
As long as an older person is working actively, he can participate in the health and welfare programs provided for all employees. Hospitalization insurance, sickness benefits, group life insurance and medical care programs may be available. For the most part these benefits are terminated when a person stops working. But that is the time when such benefits are needed most. The Committee on Aging and Geriatrics of the Federal Security Agency stated in 19.524 that 36 per cent of all people between the ages of 65 and 69, 25 per cent of those between 70 and 74, and 15 per cent of those 75 years of age or older owned some kind of hospital insurance. At present the trend is to provide hospital and surgical benefits for retired workers. Policies can be written by commercial carriers, or through Blue Cross or Blue Shield. By placing some restriction on the maximum benefits a retired employee may receive under group insurance, the cost of the plan can be held down and yet give the pensioner some protection. A 1954 survey showed that approximately 40 per cent of 327 companies of varied size provide hospital benefits for retired employees. ID RETIREMENT OF EMPLOYEES
The problem of when and how to retire employees is a major concern in many quarters. These include leaders of management and labor,
The Aging Process in Industrial Employees
31
schools of business administration and industrial relations, sociologists, and industrial physicians, psychiatrists and psychologists. The problem is complicated further by collective bargaining agreements and fixed management policies. More often than not no specific policy relating to retirement procedures or counselling exists. There are three main retirement policies in existence :10 1. Discretionary retirement, under which the company permits the employee to continue working with few or no restrictions. 2. Automatic retirement, under which the employee is automatically retired at a specified age unless he receives management approval to continue working. 3. Mandatory or compulsory retirement, under which an employee must retire at a given age, with few or no exceptions allowed. Flexible retirement policies permit retention of valuable employees. Individual decisions are possible, since persons do not reach retirement age at the same time. It lessens hardship for employees who might otherwise retire with inadequate benefits. The primary disadvantages of any flexible plan are that it may delay promotion of younger employees, create employee uncertainty about retirement, and present administrative problems in selective retirement. Mandatory retirement has the advantages of anticipation and planning for retirement by employees. It allows for promotion of younger employees in an orderly fashion, and it is easy to administer. Its greatest disadvantages are the difficulty of adjustment to obligatory retirement, and the financial burden assumed by retiring individual. A large number of retired employees with inadequate retirement benefits could handicap the general economy of the country. The attitude of employees toward retirement varies. People adjust well who have planned for retirement, have adequate financial resources, satisfactory health, and who have had continued interest in activities other than work for many years. But one of these attributes alone does not guarantee a successful adjustment. Work activities are for many employees a major form of social participation. Leaving other workers on the job causes social isolation after retirement. This situation may be temporary. It has been called "retirement shock." Counselling programs in preparation for retirement vary a great deal, but there is general agreement that counselling must be included if the program is to be successful. Yet as late as 1954, only 65 per cent of 327 .companies surveyed had initiated such programs. 10 Counselling regarding retirement may begin as soon as five years, or as late as a few months, before an employee retires. Many retirement programs concern themselves in great detail with the physical and emotional aspects of health in this age group. About three out of five workers find retirement to be a satisfying experience, whereas the other two out of five resist retirement and remain unhappy afterwards.
Harold H. Steinberg
32 SUMMARY
The process of aging in industry is best met by a consistent and sustained program of health conservation that begins with the first placement examination and continues throughout the entire span of years of employment. If properly carried out, such programs can result in increased productivity, more comfortable living, and lessened incidence of disabling disease and injury. Assuming that it is good business to have an effective medical program, small industries employing 100 persons or even fewer find it profitable to create health services. These services do not need to employ full-time personnel, but to be effective they must include all of the essential facets of an industrial health program. Studies should be conducted which give further consideration to all jobs at which the older worker can be comfortably and successfully employed. Many such employees have developed high degrees of skill and have had vast experience-attributes which can be used in many different kinds of work. It is not wise to allow a segment of the population, which within 25 years may become as large as 20,000,000 persons, to be unproductive and unemployed. The role of medicine in industry is health conservation. Tremendous strides have been made in preventing, diagnosing and treating disease. As a result, life has been prolonged and better opportunities to maintain health have been created. Health maintenance is an important role in the general field of medical care. This aspect of medical practice is exceedingly important in the work of the industrial physician. To all physicians it can be a rewarding and challenging experience. REFERENCES 1. King, W. F.: Health Guidance in Advancing Years. Proc. Institute of Geriatrics, Indiana University School of Medicine and Indiana State Board of Health, May 22, 1946. 2. U. S. Department of Health, Education and Welfare: It's Good Business to Know Your Men. Public Health Bulletin No. 379, 1954. l3. Pearlman, S. L.: The Physical Side of Aging. Industrial Relations Center, The University of Chicago, 1955. 4. Federal Security Agency, Committee on Aging and Geriatrics: Fact Book on Aging. U. S. Govt. Printing Office, 1952. 5. Hays, M.: Problems of Older Workers. Proceedings of a Conference, Janesville, Wisconsin, 1953. 6. Stieglitz, E. J.: Certain Aspects of Geriatric Medicine. Proc. Institute of Geriatrics, Indiana University School of Medicine and Indiana State Board of Health, May 22, 1946. 7. Myers, J. A.: Tuberculosis Among Persons over 50 Years of Age. Geriatrics 1: 27,1£)46. 8. Kuh, Clifford: Geriatrics in Industrial Medicine. Yale J. BioI. & Med. 19: 4 (March) 1947 9. Weinberg, J.: Mental Health Needs of the Aged. Community Project for the Aged, May 6, 1948. 10. National Industrial Conference Board, New York: Retirement of Employees; Studies in Personnel Policy, Conference Board Reports No. 148, 1955. 122 S. Michigan Avenue Chicago 3, Illinois