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• The Lancet
• (03/09/2002 17:17)

Ecco il "nostro" articolo e le risposte di Siti e Tommassini

Occupational medicine at stake in Italy

Sir--Legislation voted in by the Italian Parliament has extended to specialists in hygiene and in forensic medicine the licence to practice health surveillance in the workplace, an undertaking so far reserved to specialists in occupational medicine.

The change, which consists of a two-line amendment in a new law dealing with a different issue--the shortage of nurses in Italian hospitals--has been approved without consulting the relevant scientific and professional associations.

In the schools of hygiene and forensic medicine, education and training in occupational and clinical medicine are negligible, being limited to a few dozen hours of formal teaching and no practical training. As such, they do not meet the current standards of medical surveillance and biological monitoring of workers, let alone the complexity of industrial toxicology and risk assessment. To become a specialist in occupational medicine, postgraduates need to do a full-time 4-year course, with more than 800 h of formal teaching and about twice as many hours of practical training.

The professional associations of occupational medicine in Italy are concerned that the new law may lead to lower occupational health standards, potentially endangering workers' health. Resentment has also arisen among the Italian academic occupational medicine community. Italian occupational physicians believe their current international image has been outraged by the new legislation.

The impact of the new law, however, in terms of prevention and protection of workers' health, is likely to be overwhelmed by another piece of legislation, approved on March 8, 2002, in which a European Union directive was approved on the protection of the health and safety of workers from risks related to chemical agents at work. The directive established that where there is only a slight risk to the safety and health of workers, and if the measures taken are sufficient to reduce that risk, the protection and prevention measures, arrangements to deal with accidents, incidents, and emergencies, and health surveillance shall not apply.

The term "slight" has been translated into Italian as moderato--moderate, not extreme, limited. Therefore, the intervention of an occupational physician is not required, nor are the other procedures indicated, in the presence of a notable but not extreme risk to workers. This interpretation contradicts the precautionary principle, the much disputed but still widely used approach to risk management adopted in the European Union. Moreover, it would violate the rule that national legislation implementing European directives must not be more permissive than the original directive.

The new regulations seem set to lower standards and devalue professional skills in occupational health. The potential outcome may be the substantial reduction, or even the abolition, of the presence of occupational physicians in many Italian chemical industries.
*Maurizio Manno, Antonio Mutti, Pietro Apostoli, Battista Bartolucci, Innocente Franchini
University Association of Occupational Medicine "Bernardino Ramazzini", Via Giustiniani 2, 35128 Padua, Italy (e-mail:manno@unipd.it)


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New opportunities to improve occupational health in Italy


Sir--We were surprised that Maurizio Manno and colleagues (May 25, p 1865),1 in their discussion of the parliamentary decision to improve safety and accident prevention at working sites, choose to move to an international stage a mere corporative controversy. The medico competente (competent doctor) is one of the highest paid jobs in Italian public health.

The extension to specialists in forensic medicine and in hygiene and preventive medicine of the possibility to act as medico competente--ie, to officially be employed in the specialty of occupational hygiene, not occupational medicine--was a request that these two groups had advanced many years ago. We believe it has corrected an anomaly of Italian legislation, and is absolutely legitimate for the following reasons.

Specialists in hygiene and preventive medicine have always dealt with safety and prevention, especially at living and working sites. In universities, the discipline of occupational hygiene is taught by these members of staff and not by the specialists in occupational medicine.

Many specialists in hygiene and preventive medicine, and, similarly, many in forensic medicine, have already covered for many years positions of medico competente, which is permitted by law and satisfies employers and employees. The new law merely extends this possibility to younger specialists of both disciplines.

In the specialty of occupational health there are progressively fewer typical pathologies of exclusively professional origin. The concept of work-related factors is expanding, meaning several groups of factors, from living habits to general environmental exposures, are involved in work-related disease. Therefore, the presence of specialists in hygiene and preventive medicine is historically acknowledged, and even indispensable to the occupational physicians themselves, who are traditionally dedicated to the diagnosis and cure of occupational diseases, for a better assessment of which factors determine modern occupational diseases.

We believe that this explanation should be more than enough to legitimise the specialists in hygiene and preventive medicine as medico competente; the lawmaker, rightly, did not identify this role with that of specialists in occupational medicine because of his varied and multidisciplinary activities and the complexity of the different tasks he has to deal with, from epidemiological data processing, environmental risk analysis, training courses, to sanitary surveillance, and even to health management capability.

Apart the different disciplinary, historical, and legal arguments previously illustrated, we anticipate that the association that includes most (around 4000) of the specialists in hygiene and preventive medicine nationwide, is available to cooperate with all the other operators in the public-health system, which includes occupational physicians, to adopt common initiatives for a continuous improvement of the medico competente role, and to promote better health and at working sites.
*Vittorio Carreri, Carlo Signorelli, Paolo Marinelli, Gaetano Maria Fara, Antonio Boccia



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*Italian Society of Hygiene, Preventive Medicine and Public Health, Viale Città d'Europa 74, 00144 Rome, Italy; School of Medicine, University of Parma; School of Medicine, University of Naples "Fredrico II"; and First School of Medicine, University "La Sapienza", Rome (e-mail:sitinazionale@tin.it)
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Sir--As Maurizio Manno and colleagues discuss,1 the Italian Parliament, by a large majority, have decided to address prevention of accidents at working sites by extending responsibilities to medical staff other than occupational-medicine specialists. The low numbers of such physicians over the past 8 years has forced many companies to abstain from making safety controls.

The occupational-medicine specialists Manno and colleagues talk about are not doctors who have always studied and taken care of occupational disorders, but started as ad hoc medical figures, introduced in 1994, named medico competente (competent doctors), who deal with safety and accident prevention in working environments. According to the law, they have the following responsiblities: medical examinations of candidate employees; medical examinations of staff for ability to do a job; further medical assessment of ability to do a particular job; and environmental inspections of the company, providing written biostatistical data analysis, and training material on specific risks, first aid, and on-the-spot emergency managment.

These tasks are multidisciplinary and cannot be pertinent to one specialty. Medical examinations of candidate employees might be properly done by specialists in forensic medicine, or biostatistical data processing and training courses better prepared by specialists in hygiene and preventive medicine. Despite the logic of the objections of the specialists in occupational medicine to these measures, it also seems logical to promote new training initiatives for medico competente, such as a master's degree, to be done after specialisation courses, that will give to all specialists in public health, and eventually others, technical knowledge and practical experience that will make them able to carry out this important function.
Antonio Tomassini



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Parliament Commission for Hygiene and Health, Senate House, 00100 Rome, Italy (e-mail:a.tomassini@senato.it)