Spiralling Down

For both men and women with a permanent work-related impairment, a crucial factor that predicts whether they die early is what we call ‘work disability’ — the difficulty they face staying in the labour market,” says Heather Scott-Marshall, Ph.D., associate scientist with Toronto’s Institute for Work and Health (IWH) and lead author of a 19-year study published in the September/October issue of the Canadian Journal of Public Health.

Work disability stems from physical, psychological and emotional difficulties that people experience when coping with, or adapting to, an acquired impairment. These hardships can affect their sense of self and create problems on how they fulfill their roles as workers, spouses and parents. The findings of the study, entitled Long-Term Mortality Risk in Individuals with Permanent Work-Related Impairment, are based on a sample of 19,000 individuals with workers’ compensation claims for accidents occurring in Ontario from January 1, 1986 to December 31, 1994 that resulted in permanent impairment.

“This particular study is unusual in Canada,” says Dr. Cameron Mustard, president and senior scientist with the IWH. The study links a set of data kept by Statistics Canada with another database kept by the Ontario Workplace Safety and Insurance Board (WSIB) to examine differences in mortality rates between permanently-injured workers and a group of non-injured workers over nearly two decades.

Results indicate that the overall fatality rate among men with permanent impairments was 14 per cent, compared to nine per cent of men in the non-injured control group, which translates into a 55 per cent higher mortality risk. For women, the death rate among those with permanent impairment was six per cent, compared to four per cent in the non-injured group, or a 50 per cent higher risk of mortality.

A permanent impairment can adversely affect an injured worker’s longevity in two ways. The first one relates to how the injury has harmed the individual’s physiology. For example, a crushing injury to the abdomen may lead to long-term consequences or cause an impairment to organ function.

“I think we have all seen this in our personal experience: a family member who labours under a serious limp may be the kind of person we sense ages more quickly,” Dr. Mustard illustrates. Another way in which permanent impairment can reduce the quality of life is by compromising a person’s ability to participate in work, he adds.

The study also compares differences in mortality risk among participants with varying levels of disability. Permanently-injured female workers with no or low disability — defined as those who earn at least 75 per cent of their pre-injury income — are 27 per cent less likely to die in the follow-up period than women with high work disability or who earn less than 25 per cent of their pre-injury income. Men with no or low work disability are 38 per cent less likely to die than those with high work disability.

As well, the risk of death showed up most starkly a decade or more following the injury: the divergence in death rates between claimants and the control group peaked after 13 years for women and after 15 years for men. “This suggests to us that the risk of dying from a disabling injury can persist for decades,” Dr. Scott-Marshall says.

The study did not identify the causes of death and looks at a broad spectrum of permanent disabilities, ranging from minor to severe, Dr. Mustard notes. The health information of participants was limited to the presence of work injury, which means that researchers cannot be certain that the health status of cases and controls was equivalent at baseline. As well, the sample comprises only workers from Ontario, making for the possibility that labour-market conditions in other jurisdictions could have a different impact on employment and work disability after injury, the study acknowledges.

“The only information we can take from this confidently is there is a shorter life expectancy, in this case, workers who are injured and awarded permanent-impairment benefit,” Dr. Mustard says. “Why is a good question, and it is complicated.”

Tip of the Iceberg

John McKinnon, executive director of Injured Workers’ Consultants Community Legal Clinic in Toronto, thinks that the study is part of a growing body of research confirming that the consequences of work injuries, especially those resulting in permanent disabilities, are a lot more serious than we generally understand them to be. “This study is a wake-up call for Ontario to take a closer look at the impact of workplace injuries,” he says.

The vast majority of claims that the WSIB receives involve injured workers who have lost a very short period of time or no time at all and whose lives have not been seriously affected by their injuries, McKinnon notes. The majority of claimants with permanent-impairment ratings that the WSIB deals with are not those who have lost an arm or a leg.

“They would have fallen into that median zone of people who have been rated at somewhere between 10 [and] 15 per cent impairment,” he observes. “But there are still about 15,000 people every year who have a recognized permanent impairment. That number grows, and how we treat those people is the most important measure of whether the workers’ compensation system is doing the job it needs to do.”

Mary Ann McColl, Ph.D., academic lead with the Canadian Disability Policy Alliance in Kingston, Ontario, thinks that the study offers “very interesting preliminary findings,” but does not provide enough information to allow any specific policy implications to be drawn.

“What struck me as the chief weakness is we don’t really know anything about the nature of the disability or the cause of death,” says Dr. McColl, who is also the associate director of research with the Centre for Health Services and Policy Research at Queen’s University in Kingston. “All we have is a population-level, very raw indication that there is some sort of a relationship between workplace injury and premature death.” The only definite implication, she adds, is to fund more research to understand the relationship between specific types of disability and specific causes of premature death.

Catherine Connelly, Canada research chair and associate professor of organizational behaviour with DeGroote School of Business at McMaster University in Hamilton, Ontario, agrees. “I think it just points to the importance of finding further ways to reduce injuries in the workplace,” she says. “Some might assume that once the worker has returned to paid employment, everything is fine. But this study shows that the long-term impact of these injuries is significant.”

Firsthand Account

Steve Mantis, a 65-year-old resident of Thunder Bay, Ontario, says the study “validates what we have seen anecdotally for years.” Mantis, who does contract work for the Centre for Research on Work Disability Policy, has his own injury story to tell.

He was 28 when he worked in the construction sector back in 1978, helping to lift up a house with a crumbling foundation. “We had a winch truck moving big heavy bins, and I was just winding the cable under the winch after the job is done,” Mantis recalls. As he was doing so, his glove got caught on the cable and was pulled in, amputating his left arm within a couple of inches of his shoulder. The bone splintered and some of it got driven up underneath his arm and came up by his neck. “It was a life-changing event,” he says.

After the incident, Mantis went to see a prosthetic technician, who told him to find a good woman to look after him for the rest of his life. “I was very upset,” Mantis says. “I didn’t know whether to punch this guy in the nose or cry.”

He adds that families break down following serious injury for a number of reasons. “People become isolated, and their lives and health suffer.”

Mantis attributes the declining health of injured workers to stress and depression. The fear of risking further injury may also deter them from being physically active. “People need to be healthy mentally, physically and emotionally. And that has to do a lot of it with getting support you need in those critical times so that you do take charge. You don’t become the passive recipient,” he emphasizes. “The people I know who have lived the longest are people who are out there, active in one way or another.”

McKinnon says a major problem with the current workers’ compensation system is that it does not track what happens to injured workers in the long run after injury. “Research shows there is something about our workers’ compensation systems that is related to significantly higher levels of mental-health problems, and we need to look at that.”

There is also the cascading effect following a work injury. “A range of other health problems continue to pile on on injured workers over time, and after they have a permanent disabling work injury. In that way, you might expect there to be higher rates of premature death because of the snowballing effect of work injury on people’s health,” McKinnon explains.

Domino Effect

A report, Poverty Status of Worker Compensation Claimants with Permanent Impairments, published in Taylor & Francis Online in March, looks at the extent to which injured workers who sustained bodily impairments live in poverty.

Employing two poverty indicators — proximity to or depth of poverty and factors associated with poverty in the post-injury period — the report describes the poverty levels of injured workers with permanent impairments in Ontario at an average of 52 months post-injury. Estimated poverty rates for the injured-worker sample, which range from 17 to 26 per cent, compare unfavourably to published estimates of poverty in the general population of working-aged Canadians and equate to rates of people with disabilities.

The findings also reveal that sample members in post-injury poverty were more likely to report having sustained multiple injuries at the workplace and were less likely to have returned to employment or to have recovered their pre-injury earnings. Yet they contributed significantly more to post-injury household incomes than those who were not in post-injury poverty.

The disturbing correlation between workplace injury and poverty was highlighted in a report published in June 2006 by Street Health Community Nursing Foundation in Toronto. Failing the Homeless: Barriers in the Ontario Disability Support Program for Homeless People with Disabilities says workplace injury played a role in becoming disabled for 57 per cent of Toronto’s 85 homeless participants with disabilities who worked and that 46 per cent had received worker’s compensation benefits at some point. None of them were able to maintain ongoing benefits.

“Poverty is clearly a factor in early death,” McKinnon says.

Mantis, who received benefits following his workplace injury, speaks of the frustration and alienation he experienced   when dealing with the workers’ compensation system. “Because I had an amputation, I got the best service they had. Even so, there were bumps along the way, because there was this bureaucracy that didn’t really pay that much attention to the individual.”

Interactions with workers’ compensation boards (WCBs) can leave injured workers feeling bitter. Mantis points to the disability recovery guidelines and expected healing times used by WCBs to assist clinicians, case managers and medical advisors with the clinical management of claims. These guidelines provide the approximate time required for employees to return to work after various job-related injuries and treatments. While the maximum time given for each injury is not necessarily a definite return-to-work date — considering that many factors like, age, medical conditions, complications and treatment, which influence recovery time, must be taken into account — the timelines indicate when questions should be asked if a worker has not returned to work.

For instance, if the chart says that it takes six weeks for a certain type of injury to heal, and the recovery of a worker takes longer than that, case managers may start probing deeper. “Are you trying to take advantage? Are you trying to extend the amount of time you are on benefits?’ That is the attitude that far too often comes out,” Mantis suggests.

Different Strokes

As every injured worker’s case is different, the return-to-work program varies from individual to individual, explains Sarah Reeves, communications advisor with Nova Scotia’s WCB in Halifax. In general, the WCB covers costs of pre-approved services and personal equipment, including but not limited to those provided by doctors, chiropractors, physiotherapists, surgery, prescriptions and dental expenses.

“An injured worker would have to talk with their case worker to determine which specific services are available to them for their claim,” Reeves advises. While injury prevention is the best way to keep workers safe and reduce overall costs, putting an effective return-to-work program in place is the best way to manage the impact of an injury, she adds.

“The longer employees are off work, the less likely they are to return. So when an injury does occur, the best result for everyone is a safe and timely return to work,” Reeves says. “Creating a successful return-to-work program requires a team effort, and each partner must have a clear understanding of their role and responsibilities.” Return-to-work partners include employers, workers, WCB case workers and case-management teams, relationship managers, WCB consultants, healthcare providers and, if applicable, union representatives.

Mantis thinks that changing the bureaucratic approach of WCBs is a step in the right direction. He stresses the importance of understanding the individual and the level of support needed.

“The interaction takes away, in many cases, people’s own initiative,” Mantis says, referring in particular to the way in which WCBs identify injured workers by their claim numbers. “I refused to memorize my number. I won’t. You want to deal with me? This is my name. Here I am. I want to maintain that I am a person.”

Dr. Mustard thinks that while much emphasis has been put on the principle that employers cannot discriminate against people with disabilities, “we have not gone far enough.” The key message of the IWH study, he says, is to create opportunities for people with disabilities. He cites Ontario and British Columbia as provinces that have well-administered permanent-impairment programs.

“These programs,” he says, referring to two people with the same permanent impairment getting the same treatment, “are very difficult to administer fairly.”

While other disability income-security programs, such as employer-based long-term disability plans, are available, these programs do not meet the same standards as provincial workers’ compensation programs in terms of providing economic security to injured workers. He stresses the importance of protecting them and ensuring that they are strong in the future.

McKinnon thinks that it is time to start checking in on injured workers and conducting long-term studies to find out what is happening to them. “The fall from being a proud worker happens much more quickly for injured workers than it did 30 years ago,” he observes. “We can do better.”

Jean Lian is editor of OHS Canada.