Norwegian industry and health promotion 1910-1967

Norwegian Industry and IHealth Promotion 1910-196'7 HILDE IBSEN (*) SUMMARY Introduction. 1.-Occupational health service, its roots and motivations. 11.-Health, security and well-being. The individual health control at Freia. Individual health control at Christiania Portland Cement Factory. Industrial hygiene and the collective work environment. Industry and health promotion. Conclusion. RESUMEN Se estudia el desarrollo de los servicios de salud ocupacional en Noruega a través de los ejemplos de sendas fábricas de chocolate y cemento. El estudio muestra cómo los servicios de salud industrial estuvieron determinados por diferentes motivos o posiciones ideológicas. .Entre estos destacaron la presencia de una filosofía social y política, la del estado del bienestar como una alternativa al socialismo, y la de una política estatal preocupada por la construción de una sociedad opulenta y el incremento de la producción. Todo ello condujo a un interés creciente por la influencia del factor humano en la industria, en la que al médico empleado le cumplía el deber de contribuir a conformar un trabajador satisfecho, consciente y productivo en un ambiente de trabajo sano. INTROD UCTION In Nonvay the history of the occupational health service starts at the end of the 17th century. The new mining industry brought changes in social and hygienic conditions and engagedl doctors who mainly worked Fecha de aceptación: 21 de septiembre de 1992. (*) School of Cultural and Social Studies, University of Oslo, P.O. Box 1056 Blindern. 0316 Oslo 3. Noruega. DYNAMIS Acta Hispanica ad Medicinae Scientiammque Histwiam Zllustraadam. Vol. 13, 1993, pp. 155-172. ISSN: 021 1-9536 156 EIILDE IBSEN l~ith treatment and cure. They had little responsibility for hygiene and l~revention. About 1910 the old works doctors disapeared. They were no longer needed. According to the Sickness Insurance Act (1909) a number of workers were given free medical treatment "and money during illness. At the same time industry paid more attention to work environment and hygiene. The time had come for a modern industrial health officer (1). 191'7 was a turning point. The first modern industrial medical officer ?was employed at A/S Freia Chocolate Factory. In the year to come Nonvegian industry developed a range of voluntary social measures. The occupational health service was only one amongst various measures as housinig, pensions, profit-sharing, welfare officers, etc. Why did Nonvegian industry engage medical officers? E[ow did the arrangement work out in different factories? In what way did industry influence the development of Nonvegian health policy? In this article 1 want to explore the development of occupat.iona1 health by making a case study of A/S Freia Chocolate Factory in Oslo and Christiania Portland Cement Factory (CPC) in Slemmestad, a village thirty kilometers south of Oslo. A study of these two factories show how different motives and ideological positions promoted the industrial health service. 1 will argue that the development at Freia was a result of the managers' (Johan Throne Holst) social and political philosophy. He widened the goals of his business to include not only profits and efficency, but also social and political responsibility - noblesse oblzge. He wanted welfare capitalism as an alternative to socialism and state policy in building the affluent society (2). (1) NATWG, Haakon; THIISEVENSEN, Eyvind (1983/ 1989). Arbeidsmie~ og ikke. Yrkeshygiae og bedriftshelseijenestens frembrudd og utvikling i Norge. ( Work Environm.ent and Health. Industrial Hygiene and ¿he Foundation and Deuelopment of the Occupational Health Seruice) , Oslo, 1The Norwegian Association for Medical Officei:~, p. 74. (2) Occupational welfare and welfare capitalism is analysed in several works. See for example, BRANDES, Stuart (1976). Amen'can Welfare Capitalism 1880-1 940, Chicago/ London, Chicago University Press, 210 pp.; BRODY, David (1968). The Rise and Decline of Welfare Capitalism. Zn: John Braeman; Robert H. Bremer; David Brody (eds.), Change and Continuity in Twentieth-Centuly America: The 1920's, Ohio, Ohio State University Press, pp. 147-178; EDWARDS, Richard (1979). Contested Tmain, New York, Basic Books Inc., 261 pp.; LAZONIC, William (1990). Competitive Advantage on ¿he Shop Floor, Cambridge Mass./London, Harvard University Press, pp. 240-251; Norwegian Industry and Health Promotion 19 10196'7 157 But the occupational health service must also be seen as a means to improve the production. Cleanliness had high priority in a chocolate factory were the products had to be of the best quality. When CPC got a medical officer thirty years later, no one mentioned welfare capitalism. The motives were more rooted in the strong productivity strategy which developed in Nonvegian inclustry after the Second World War. The need for increased production also resulted in a growing interest in the human factor in indbstry. Every worker should be accepted as an individual so that he could feel physical and psychical well-being. The medical oficer should help to shape a satisfied, rati'onal and productive worker in a healthy work environment. I. OCCUPATIONAL HEALTH SERVICE - A'S ROOTS AMI MOTNATIONS The first modern occupational health slervice was established on the initative of Freia Chocolate Factory. Johan Throne Holst, the manager, wanted to make Freia a leading factory both socially and commercially. He had housing policy very much at heart and in 1910 he started to build a garden city for his employees. Few years later Throne Holst wanted to expand his building project, but the municipality refused to cooperate. He was very disappointed, but he didn't stop dreaming of Freia as an ideal factory. He found new solutions. Throne Holsts brother, Peter F. Holst who was a doctor, introduced him to Carl Schiatz, an active doctor who put great efforts into promoting nutrition and hygiene. Throne Holst knew about Schiatz' doctoral thesis about mass-examination of Nonvegian school children, and he asked him to carry out systematic examinations of his employees (3). Throne Holst stressed that hygiene was a very important question. In his ideological writing from 1914, Industy and Industrial A~oblems, he claimed that ~the MELLING, Joseph (1991). Industrial capitalism and the welfare of the state: the role of employers in the comparative development of welfare states. A review of recent research. Sociology, 25, 219-239. (3) STRDM, Axel (1975). Bedriftshelsetjenesten i Norge - bakgrunn og prinsipper (The Occupational Health Service in Norway - Background and Principles). In: 0ivind Larsen (ed.) , Forebyggende medisin (Preventive Medicine), Oslo, pp. 150-157. HILDE IBSEN people who neglect their hygiene will sooner or later collaps» (4). He linked personal hygiene to national economic guestions. A poor personal hygiene weakend the nations' health and had bad consequences with regard to production and competitive power - both important elements in the philosophy of welfare capitalism. To promote occupational welfare the industry needed profit. Throne Holst and Schi0tz met in mutual interests. They both had ideas which they wanted to test .and made Freia a starting point of a social experiment. Throne Holst wanted to try out his social political ideas, while Schiotz worked hard to promote hygiene and preventive medical work. At Freia he was given free hands and he translated his ideas into practice. Protection of the workers had become a main issue in the previous years. Work environment was a crucial question. Schiotz claimed, however, that collective public measures crowded out the individual humane hygiene. Al1 remedies had to be used to make the human being healthy and to increase its capacity both physically and intellectually. Research concerning protection alid environment was important, but it had to be done in cooperation with clinical-medical examinations of the industrial worker. Schiotz build up the occupational health service according to new principles. He used the same methodes as he had used in examining schoolchildren. His task was not to cure but to do preventive and consultative medical work. He commented on the workers health and their ability to work. He worked for the improvement of work conditions aind he tried to stimulate the workers to a healthy and hygienic way of life. The main purpose was to give the factory a strong and healthy workirig staff. It took years before doctors and managers became interested in the occupational health service. Freia was alone for nearly twenty years (5). Some ofiicers in the State Labour Supervision tried, however, to spread the gospel of occupational health. They wanted the public supervis~ors to promote hygiene in the factories. Traditionally these supervisors had been more (4) THRONE HOLST, Johan (1914). Zndustri og industrielle problemer, Kristiania, H. Aschehough & Co., p. 4. (5) BRUUSGAARD, Arne (1943). Bedrifshelsetjenesten (the Occupational Health Se~ce). Liv og Helse (Life and Health), 10, 51-52. Norwegian Industry and Health Promotion 1910-1967 159 interested in making technical improvements than in improving the workers health (6). In the early thirties doctors took more interest in the question of occupational health. Schiatz' work at Freia and his teaching at the university gave results. When Schiotz died in 1938 four doctors who had been Schiatz' students, continued his work. Some of them were radicals, like Arne Bruusgaard and Axel Strom (7), and al1 of them had got their education during the expansion of social medicine in the thirties. One of them, Eyvind Thiis-Evensen, worked out directives for the occupational health service in his lecture for the doctoral thesis in 1941. He wanted al1 enterprises with more than fifty employees to establish the arrangement. He proposed that al1 directives should be made by the Professor of hygiene at the University of Oslo and the chief officers in the State Labour Supervision. In 1943 eleven enterprises had engaged an industrial medical officer - only two in 1940. The arrangements differed and in severa1 factories neither the managment, workers nor the cloctors were satisfied. During 1943 the periodical Liv og Helse (Life and Health) published a number of articles concerning industrial medical officers and got positive response from a number of enterprises. At the end of 1943, fiftyfour enterprises had got an occupational health service build on Schiotz' model. The need to find similar directives increased dunng 1943, and Bruusgaard, Natvig, Stram, Thiis-Evensen and Eiler H. Schiatz (Carl Schiotz' son) joined together in the Association of Industrial Medical Officers. They wanted support from the medical establishment but the Nonvegian Medical Officers Association was out of function because of the war. Instead they started a co-operation with the Nonvegian Hygiene Association (8). The war limited their work, but they managed to publish brochures which gave advise to doctors who wanted to practice as industrial medical officers. During 1944 the association distributed two brochures to al1 the members (6) NATWG; THIISEVENSEN (1983/1989), op. nt (n. l), p. 60. (7) NORDBY, Trond (1989). Karl Euang. En bzografi, OOs, H. Aschehough, p. 55 and p. 182. Arne Bruusgaard was one of the committe members of the first board of the Socialist Doctors Association from 1931. Axel Str~m was a member of the association. (8) The Norwegian Hygiene Association was, however, an association within the Nonvegian Medical Officers Association. 160 HILDE IBSEN of the Norwegian Hygiene Association. They also made a standard contract for industrial medical officers. When the war was over Bruusgaard discusseíl the future of the occupational health service with one of the Workers' Associations on a conference in spring 1945. The workers had two main objections. They feared that workers would be decleared disabled for medical reasons and they feared that the industrial medical officers would serve the employers interests more than the workers (9). The Association of Industrial Medical Officers found the objections legitimate and suggested the establishment of a secretariat with represe*tatives from the Trades Union Congress and thle Norwegian Employer's Federation. Bruusgaard claimed that it was impossible to secure the arrangement without support from the two organisations. During that summer Bruusgaard got in touch with the secretary of the Trades Union Congress, Konrad Nordahl. He showed some interest but dicln't suggest a co-operation. The office manager in the Employer's Federation was reserved. The question of co-operation was allowed to rest. Instead the Association of Industrial Medical Officers concentrated on getting support from the Medical Officers Association. In september 1945 the subject was put on the agenda of the association's yearly conference and it was in principle approved. In February 1946 the Association of Industrial Medical Officers tried once again to establish a co-operation with the Trades Union Congress and the Employer's Federation. In the mean time both organisations had made a closer examination in enterprises which had engaged industrial medical officers. The experiences were positive, and the Board of Industrial Medical Officers was established on May 22 1946 with representatives for the Trades Union Congress, the Norwegian Employer's Federation and tlie Association of Medical Officers (10). Haakon Natvig was elected presidenir of the board. Why was there an increased interest in the question of the occupational health service from 1943? How was it possible after such a short time to establish a new board comprising traditionaly c'ontending parties? Haakon Na~ig has claimed that the time for it had come (1 1 ). Experiences from different enterprises showed that the occupational health service was a practica1 and economical solution to the question of both health and (9) NATVIG; THIIS-EVENSEN (1983/1989), op. cit. (n. l), p. 90. (10) Ibidem, p. 106. (1 1) NATVIG, Haakon (1953). Bednfshelsetjenestens fremtid (The future of the Occupational Health Service), Lzv og Helse, 19, 104107. Norwegian Industry and Health Promotion 19 101967 161 work environment (12). The industry had to show the way together with doctors. «We cannot wait that the State in near future will be able to arrange such a health control» (13). The increased interest in the question nqust also be seen in conection with the employers' wish to reduce the sick.ness rate by stronger control. The sickness rate was increasing and some enterprises used the medical officer as a 'policeman'. Other factories had problems with certain diseases like tuberculosis, silicosis and lead poisoning. By establishing a permanent health supervision the managers wanted to make an effective campaign against diseases. But in many cases employers had acknowledged a wider social responsibility for their employers dui-ing the war. ~Since we have been poor in other respects, it seems that the interest in good health and working power has increasedu (14). From the doctors point of view the work as industrial medical officer was well paid and gave interesting work. The Board of Industrial Medical Officers was founded in a time when everybody wanted to reconstruct the damages of the war. Both the board and the agreement on Production Committees was «a promising evidence that the will to co-operate was stronger than conflict on interests. (15). To improve the popular health and the workers social circumstances it was necessary to combat illness and to improve the hygienic conditions in industry. While infant welfare clinics and health control of schoolchildren was a good service for children, adults had inext to nothing. The health service was causal (16). Most of the population had free health examination and treatrnent, but there were no good preventive services. Regular exarnination of apparently healthy people was one of the main purposes in preventive medical services. These services had to be expanded and be offered to the majority of the working population. The occupational health service expanded between 1947 and 1949. No other social health service had any similar development in such a short time. In 1952 about 500 enterprises had an industrial medical officer, that is 7,7% of industrial enterprises with more than five employees (1'7). The (12) Ibzdem. (13) BRUUSGAARD (1943); op. cit. (n. 5), p. 51. (14) Ibzdem, p. 52. (15) I,zv og Hehe, 13 (1946), 153. (16) BRUUSGAARD (1943), op. cit. (n. 5), p. 51. (17) NATViG (1953), op. cit. (n. ll), p. 104. 162 HILDE IBSEN percentage varied between 1,8% ti11 16,9% in different parts of Norway. The arrangement was most common in counties around Oslo. Around 1965 abouit 1.500 enterprises were coVered by the occupational health service (18). This development corresponded with" greater interest in the human factor in industry. In addition more and more managers realiised that they had social responsibility. However, the main reason for the expansion must be seen in connection with the growth of the rational and productive society. The employers had to increase productivity by getting a strong and healthy workforce. Not only technical means of production had to undergo rationalisation, but the workers too. In this work the industrial medical officer had to make a ~healthy and proper rationalisation of the main means of production - the human beeing~ (19). II. HEALTH, SECURITY AND WLL-BEING The individual health control at Freia When Schiatz started to work at Freia he organized the health service according to his own ideas and principles. The lines he layed down were later followed by the Board of Industrial Medical Officers. New methods were drawn up: individual health control, registration of absence and hygienic work. For several years the modern factory docto'r concentrated on the individual health control (20). It was necessary to examine the human being before further control of the hygienic conditions. When the doctor had analysed tl:e workers and their diseases it was easier to find connections between illness and work environment. Schiatz worked as a part time doctor with two working hours a week. Al1 employees were examined once a year. Schiotz called for six to eight workers every time. Both men and women were stripped to the waist, but the women kept the bra. The workers gave i.nformation about previous (18) NATVIG; THIIS-EVENSEN (1983/1989), op. cit. (n. 1) p. 145. (19) 12iv og Helse, 13 (1946), p. 153. (20) STRaM, Axel (1957). Fravaeret ved en norsk betlrift i etterkrigsWarene (Abscence within a Norwegian factory in the after war period). Sosialt Arbeid (Social Work), 10, 209-220. Norwegian Industry and Health Promotion 19 1019617 163 work and illness. Schiotz examined hands and teeth. Freia was a nutrient factory and Schi~tz paied great attention to personal hygiene. Furthermore he examined the skeleton and feets. He sourided heart and lungs, measured height and weight. If a worker was ill he was sent to a general practitioner or a specialist. Schiotz had made an agreernent with the Board of Health in Oslo in case of tuberculosis. The examination method was very simple. Few methods existed which were usable for mass-examinations. Schi~tz based his diagnosis on «a practiced eye», which was efficient according to the clinical picture of the time. The most common illnesses were eczema and dermatitis, angina, diphtheria, bronchitis, consumptives and rheumatism. Caries was also a serious problem. In spite of a simple and maybe imperfect ~examination Schiotz' methods represented something new. Schiotz, created the basis of a systematic health control of grown up people (21). When Axel Str0m followed Schi0tz in 1938 he developed the examination methods further. The workers undressed and Strom used half an hour on every worker. He made an urinalysis and he took a blood test and a Pirquet-test. He measured the blood pressiire. Every employee got their own book where Str0m marked information about illness and results of the examination. Did the doctors' work give results? How were the health . conditions at Freia? In spite of the industrial medical officer and other welfare measures the sickness rate at Freia was very high. Investigations of abscence and surveys on diseases got high priority. Str0m plannecl a survey on the sickness rate when he started his work in 1938. Because c)f the war it was impossible to bring it about in the way he had wanted. However, he registred the abscence and he presented the results in the periodical Sosialt Arbeid (Social Work) ,in 1949. Few years later he imade a new survey which he presented in the same periodical in 195'7. At that time abscence in industry had become a serious social and economical problem. 1 The abscence at Freia increased dramaticaly between 1940 and 194'7. Every year the sickness rate was higher for women than for men. In average (21) Inte~ew Haakon Nabig 27.2.1991. See also NA'I'VIG; THIISEVENSEN (19831984), op.cit. (n. l), p. 78 and NATVIG, Haakon (197:!). Den norske ~edriftslegeoriningen - i fortrid og fremtid (The Nonvepan Occupational Hetalth Seroice - the Past and the Future), Oslo, p. 5. 170 EIILDE IBSEN As we have seen, the sickness rate at Freia increased after the second world war. At that time there had been a medical officer at the factory for nearly thirty years. Based on his own experiences Str0m could not find a good answer, and in general it was too early to study the connection between the occupational health service and the sickness rate. The arrangement had, however, created an understanding of a healthy way of Xife (33). In the fifties and sixties the clinical picture changed. Chronic diseases like cardiovascular diseases, malignant tumors and myalgies dominated. Mental diseases and difficulties of adjustment also increased (34). The demand for a healthy work environment was strengthend. The environment had to be stimulating and pleasant. Did the industrial medical officers adjust to this development? A study of Freia and CPC shows that the medical' officer and the management tried to follow the social development. When the claim for stimulant and well-being increased, Strem and Engebrigtsen co-operated with the management, for exemple, in trying to promote rehabilitation within the factory. CONCLUSION In my analysis of the occupational health service 1 have focused on the motives behind the arrangement, how it was organized andl in what way industry influenced Nonvegian health policy. My case study has shown that the occupational health service - like other industrial welfare measures - has many-sided explana~tions (35). In the first place it was a part of the welfare capitalist movement which also took place in other western european countries and the USA. The welfare philosophy which developed at Freia was originally ideological and visionary. Throne Holst was radical in his youth, but went conservative after some (33) Zbidem. (34) STR0M (1975), op. cit. (n. 3), p. 154. (35) Some viewpoints are that occupational welfare developed as a new strategy in the trancition from paternalist to corporate management, that occupational welfare was a part of ethical or philantropic management and a weapon against trade unions. Cf: note 2. Norwegian Industry and Health Promotion 19101967 171 years as Freias' manager. But he was still ideological and as a struggle against socialism he wanted to build a society without a proletariat. In that world, however, the working class culture was lost. An important element in the welfare capitalist ideology was profit. I:t should not only enrich the factory owner, but be used as a means to serve the nation. Healthy and strong workers were productive and necessary for the competitive power. In the second place the occupational heíilth service was a part of the strategy to increase production and to rise the popular welfare. Workers who felt safe and well-being were effective and! loyal. A great many factories build up occupational welfare measures after the Second World War - ,CPC is just one exemple. During the fifties and sixties the occupational health service became the most common welfare measure in addition to pension systems. In the way the occupational health system was practised we can follow the principles from 1917 up to these days. The arrangment has focused on collective and individual hygiene and preventive medical work. But a subject of debate among medical officers has always been wether the occupational health control has been nothing else than ~nneat inspection». It is difficult to make a comprehensive evaluation of industry as health promoter. But the analysis of Freia and CPC shows that the occupational health service was important in the development of industrial hygiene. The arrangement forced better sanitary conditions, well-being and security. It is, however, more difficult to asses the extent to which the occupational health service has reduced illness. But the industrial medical officer has probably contributed to reduce occupational cliseases and injuries. Serious diseases have been discovered early. The workers have got free regulary health control and opportunities to ask for advice. With the occupational health service, industry took an initiative which has benefited most working people. Axel Strom claimed in 1975 that the occupational health servie would never have developed if industry had not lead the way (36). Neither the Public Health Adininistration nor the Medical Officers Association showed interest in the lirrangement. The post-war Health Minister, Karl Evang, never gave the industrial medical officers any status. Thiis-Evensen claimed that he even prevented an adequate development (36) STR0M (1975), op. cit. (n. 3), p. 157. 172 !HILDE IBSEN of the occupationai health service (37). He, like the Medicai Officers Association, might have feared competition in relation to the general praceitioners aod their economic basis. When the Report from Parliament on the Primary Health Service was presented in 1971 the occupational healtli service was scarcely mentioned. But the Board of Industrial Medical Officers took action and the arrangement was given more attention. The Trades Union has, however, been positive. In the seventies it wanted the arrangement to expand. The Employers' Federation also agreed on the importante of the occupational health service. When Thiis-Evensen wrote his article in 1975 he hoped that the Medical Officers Association would give more attention to the arrangement in the future. He was sure the occupational health service would continue to expand, and he hoped that the public health would take over the administration when the authorithies were ready. It would, however, not happen in the near future (38). In the lmean time doctors with particular social interest had an important task: to promote preventive medicine together with the industry. - (37) THIIS-EVENSEN, Eyvind (1975). The Iildustrial Medical Office -- an Outsider in Norwegian Public Health?, On: Larsen (ed.), @. cit. (n. 3) p. 159. (38) Ibidem, p. 163.