Occupational Medicine: State of the Art Reviews

Edited by Peter Schnall, Karen Belkic, Paul Landsbergis and Dean Baker
Published by Hanley & Belfus, Inc. Occup Med 15(1), 2000


1. Review by Anders Knutsson, MD
Scand J Work Environ Health 2000;26(5):455

In textbooks of cardiology the impact of the work environment on the cardiovascular system is seldom discussed. Usually, the interest is in different life-style factors (eg, diet, leisure-time physical activity and smoking). Therefore, this review fills an important gap in the literature on this vital subject. The authors estimate 35,459 deaths and 289,320 new cases of disease per year due to work-related circulatory diseases in the United States. The estimated cost for 1998 was USD 22.5 billion. Work-related cardiovascular disease is responsible for more deaths than any other job-related disease.

The book starts with a comprehensive review of the evidence of an association between shift work, job-related stress and cardiovascular disease (CVD). It concludes that both shift work and job strain are associated with an increased risk of heart disease (CVD). The role of the central nervous system as a bridge between the external milieu and the cardiovascular system is duscussed in another chapter. Different mechanisms and causal pathways are postulated. Yet another interesting chapter describes how to measure psychosocial workplace exposure variables. Self-report questionnaires and external assessments of job characteristics are the major tools.

Different scientific measurement techniques are discussed, for example, ambulatory blood pressure measurements, heart rate variability and 24-hour eclectrocardiology.

A practical guide for the clinicial is provided in one chapter, which gives advice on how to perform a clinical evaluation of occupational stressors relevant to the cardiovascular system. It is recommended that blood pressure be measured at the workplace so that the diagnostis and treatment of the patient can be improved.

Karasek’s job-strain model is extensively discussed in the book. This model postulates that strain occurs when there are excessive psychological work demands, together with low job-decision latitude. Thus the model is 2-dimensional and interactive. One problem is how to assess the evidence in support of the job-strain model. For example, if a study shows that job control is associated with heart disease, does its findings support the job-strain model? In keeping with the criteria stipulated previously, the answer is no. My concern is that the authors lump the job-strain model together with its singular components. This approach makes it difficult for the reader to evaluate the evidence supporting the job-strain model.

Yet another problem concerns inconsistent inclusion criteria when the literature is reviewed. When shift work is discussed in relation to heart disease, cross-sectional studies and studies using ecological exposure variables are excluded. On the other hand, when job strain is reviewed, cross-sectional studies are included and ecological exposure variables are accepted.

Despite its weak points, The Workplace and Cardiovascular Disease is an important book and useful reading for both researchers and clinicians. Hopefully, the book will increase interest in the potential to use the workplace to prevent cardiovascular disease.


2. Hazards: April/June 2000

Hazards is a not for profit publication, available by subscription. Contact Hazards by e-mail: sub@hazards.org.
Hazards / PO Box 199 / Sheffield / S1 4YL/ England


Work and Heart Disease

The Workplace and Cardiovascular Disease marks the moment when heart disease caused by work becomes a major priority to be tackled by workers and employers.

The medical establishment in the UK is only just recognizing what scientists from Scandinavia, North America, and Michael Marmot in London have been saying for 20 years. Stress at work causes heart disease.

This book describes the evidence, what has been done about it (interventions at work) and what should be done about it (reorganisation of the way we all work).

In this book you will find which jobs carry the highest risk of heart disease and what aspects of work cause it. You will find how to interpret blood pressure measurements and cholesterol levels – familiar parts of healthy living propaganda – for what they can tell you about work.

After reading this book you will know that blood pressure measurements at work tell you as much about what work is doing to your heart as about your lifestyle or family history of heart disease. Employers may find that health screening in company time – a gesture to help workers with their lifestyle problems – backfires on them.

This book lives up to its “State of the Art” label; all the major authors in the field are featured. The evidence here suggests that occupational heart disease may be the largest contribution work makes to death and ill-health.

Persuade your library or union to buy a copy. It is technical in parts, but well worth working at.

Simon Pickvance

3. Review by Norman M. Kaplan in Hypertension
Clinical Professor of Medicine, University of Texas – Southwest Medical Center, Dallas, Texas

On the same day that I rather hastily reviewed this book, 2 other experiences highlighted its main message: today’s workplace and the strains that are imposed on most working people are major contributors to cardiovascular diseasse in general and to hypertension in particualar. The first of these experiences was riding in a taxi through Manhattan to New York LaGuardia airport, and the second ws viewing Boiler Room, a movie about a group of young men selling worthless securities over the phone to naive buyers (including physicians). Seeing the frenzy, the physical and psychological stress, and the frustrations of the cabdriver and the stockbroker, people o the 2 extremes of American occupations, brought home the reality of what is described in this book.

As the 4 editors and 34 other contributors repeatedly document, we are all threatened by Karoshi: the Japanese term for death from overwork (as described in the chapters on Working Life in Japan). It’s really not so much overwork but “job strain” that seems to be doing us in. Throughout the 300-plus pages, this message comes through loud and clear. To the author’s credit, every aspect of the role of job strain in causing cardiovascular disease is covered, including both theoretical and practical solutions to the problem.

This subject deserves more attention. The book is a well-referenced , up-to-date portrayal of the field. However, it’s more like viewing a painting by Kandinsky than a Monet. The coverage is chaotic, repetitive, and disorganized. But it’s unlikely that anything important in the relationshop between job strain and cardiovascular disease/hypertension is not covered. Some really heavy editing would have helped. Even better, if the 4 editors, singly or together had done all of the writing, the book would serve more as a textbook and guide to the outsider who is just learning about the subject than a hard to follow and rather rambling presentation of everything that is known for those who are knowledgeable about this field.

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