Abstract(resumo):

Despite advances in occupational health and safety (OHS) policies around the world, the problem of occupational accidents and diseases intensifies in various economic sectors, with cuts based on gender, race, income, and occupation. This paper aims to answer two research questions: What are the main contradictions for the development and implementation of OHS policies? What are the implications of overcoming these contradictions in an attempt to improve OHS policies? Based on two previous scoping reviews developed to identify historical contradictions for Brazil and France, we performed a qualitative analysis of common contradictions of both countries using the CulturalHistorical Activity Theory. Subsequently, we present how they appear at different levels and propose implications and challenges on OHS policies in order to mediate the identified contradictions. We concluded that tension between economic growth and sustainable work systems is a primary contradiction that leads to other such hindrances in prevention tools, the social agenda, and interinstitutional articulation concerning occupational health. While presenting alternative pathways, this article serves to support the formulation, updating, and implementation of OSH policies.

Keywords(palavra-chave):

Occupational safety. Occupational diseases. Sustainable development. Social determinants. Health policy.

Content(conteúdo):

Background
Occupational accidents and diseases have significant human, social, and economic costs 1. The prevalence of fatal accidents at work in Brazil has dropped over the last two decades from 13 to 7 deaths per 100,000 workers2. By contrast, the most severe accidents are concentrated in the central region, where mining, agriculture, and livestock activities are expanding, and where the mortality rate is above 11 cases per 100,000 workers3. This general decline could be explained by the invisibility of data from the country's rapidly growing informal sector. To illustrate the impacts of informal sector growth, from 2011 to 2021, there has been a 66% increase in hospital admissions due to motorcycle traffic accidents. Despite this, data from 2021 shows that only 18% of all deaths by motorcycle traffic accidents were simultaneously reported as work-related deaths. The higher prevalence of young black people among the victims raises the hypothesis that most of those deaths are related to delivery work by apps or home-work-home journeys3,4. Furthermore, a national database showed that cases of mental disorders related-to-work increased by 3.5-fold between 2012 and 20223. However, there is no immediate resolution in sight, as new and abusive work management models have recently been implemented due to the labor reform, in place since 2017, as well as to the COVID-19 pandemic5.
In France, the prevalence of occupational fatalities is 2.6 deaths per 100,000 workers2. There have been annual decreases since the early 2000s. According to national services for Occupational Health and Safety (OHS), these results have been relatively stable since 2017. However, analyses have shown that this decrease masks differentiated effects regarding such variables as gender and economic sectors6. While construction continues to be the most accident-generating sector for men, the service sector, notably care jobs, reports the highest number of work-related accidents for women. From 2001 to 2019, the number of salaried workers in the care services sectors rose by 22%, and work-related accidents for women rose by 110%. During the same period, in the construction sector, the number of salaried workers increased by 40%, and occupational accidents concerning men fell by 30%6.
Despite economic, social, legal and cultural differences, alarming numbers from occupational deaths, accidents, and diseases in France and Brazil indicate flaws and limits in OHS policies. Focusing on this issue, a research cooperation project between both countries has been ongoing since 2019, seeking to develop Occupational Accidents and Diseases Prevention (OADP) strategies at different levels and in various economic sectors. Both countries have public health systems, and problems of inadequate public prevention policies, and could thus learn and move forward cooperatively.
Hence, this article aims to answer the following research questions:
1 - What are the main contradictions of OHS policy development as revealed by cultural-historical activity-based analyses from both countries?
2 - What are the potential avenues for overcoming these contradictions in an attempt to reformulate OHS policies?
Public policies and contradictions
This study was based on the framework of Cultural-Historical Activity Theory (CHAT)7, which analyzes the tracking of sociotechnical change8. Activity Systems (AS) are defined as historical systemic collective formations that are directed and defined by an object. In the context of OADP, the shared and fragmented object can be found between multiple AS.
In this sense, safety regulations can be understood as the product or temporary outcome of a number of interacting AS historically evolving through contradictions, which are historically inherited tensions within and between AS and, consequently, the source of potential change and development7. In this sense, conflicts, dilemmas, disturbances, ruptures, problems, or local innovations are understood as symptoms or manifestations of historical contradictions within and between the elements of AS7. It can be argued that work-related accidents and illness can be seen as manifestations of these contradictions and the resolution of those contradictions would drive the development of OADP.
Highlighting these contradictions is essential for three reasons. First, it enables us to account for the underlying structural causes for work-related accidents and illness. Second, it allows us to account for the historically situated nature of those events. Finally, it allows us to outline possible avenues for prevention systems and public policies.
The present study examines public policy as a collective activity, involving different institutions, services, and sectors, and not as mere regulations. OHS legislation is an important part of public policies, but it is not limited to it; in other words, policies are not merely what is prescribed, but rather what is put into action. Public policy is a dynamic activity that is socially and historically rooted, with an object in constant expansion. It is also an instrument used to carry out prevention practices. This dynamic evolution can be interpreted as a developmental movement, consisting of various stages.
Considering AS to be open and interconnected, the primary contradiction can lead to others among the AS elements (object, subject, instruments, rules, community, and division of labor) or among different AS within a network. When the activity object changes or expands the elements to deal with a contradiction, they are promoting the development of their own activity7. There are several AS that attempt to control a never fully controllable object, i.e., the occupational accidents and diseases determined by the socio-historical construction of work processes (Figure 1). This can be conceptualized as a runaway-object, defined as a common object that can be conceived quite differently by different stakeholders. Its boundaries are difficult to draw; therefore, it is in constant transformation. It becomes extremely difficult to work with this object, given that, while some activities attempt to control or decrease it, others attempt to strengthen or increase it. Moreover, in other cases, the very systems that try to control the object also seem to be submissive to it9,10.
A brief context of Brazilian and French policies
The implementation of main public prevention policies began during the 19th century in France and in the early 20th century in Brazil, with measures designed to protect the most vulnerable populations, including children and pregnant women, as well as to regulate both working hours and hygiene measures in workplaces.
In Brazil, during the 1940s, the government unified existing labor laws, with regulated working hours and specific measures against occupational exposures. In the 1970s, the military government in Brazil implemented a policy based on the model produced by the World Health Organization (WHO) and the International Labor Organization (ILO) for the institutionalization of OHS services in companies and the organization of regulatory standards for work environments. The technocratic discourse was aligned with the exercise of power and the control of workers’ behavior.
Concurrently, a nascent industrial working class emerged, representing a new social and political subject. Their lived experience was shaped by an awareness of the contradictions that characterized late industrial development 12. These union movements advocated for the involvement of public health services in addressing work-related health issues. Consequently, the Workers’ Health (WH) approach was promoted, inspired by the social medicine movement in Latin America, and by the experiences of the Italian workers’ movement13. WH National Conferences, carried out every decade since the 1980s, became a significant milestone in the incorporation of the concept of work processes, the operationalization of WH actions within the Brazilian Unified Health System and the promotion of participatory surveillance in workers' health. These and other actions assumed concrete forms at the beginning of the 21st century. There was the creation of the National Network of Integrated Actions for Workers’ Health in 2002, the National Policy on OHS in 2011, and the National Policy on Workers’ Health in 2012.
Despite the advancement of legislative processes, the current practices in Brazilian public services for WH surveillance, as well as private health services within companies, face challenges in controlling work-related diseases and accidents, which are typical of a low to middle income country, coupled with the injuries resulting from new and more aggressive forms of work management.
In France, the most significant advances, however, came in 1946, after World War II, with the creation of the social security system, with a specific feature: link prevention and compensation through rate-setting for firms. Moreover, companies established social dialogue bodies in collaboration with trade unions, with the objective of jointly addressing OADP. One such body is the health, safety, and working conditions committees set up in 1982. These bodies are responsible for the implementation of a collective approach to risk prevention with employees, their representatives, occupational physicians, and company management.
The next significant advancement was the introduction of European legislation. In 1989, a European Guideline introduced the principle of a priori risk assessment and adaptation of work for human needs in all member states of the European Union. In France, this led to the introduction of the “Document Unique”, in 2001, for the Assessment of Occupational Risks, which became a mandatory tool for all companies. In this document, all occupational hazards must be listed and assessed, and an action plan must be set up to prevent harm to workers. These risks may be technical or physical, or may be linked to the nature of the work and its organization.
Despite the gradual expansion of these systems, OADP continues to be an important issue for workers, public authorities, and companies. The links between work and health are often complex, due to the time taken for health problems to appear, or for exposure to be monitored and documented. The fragmentation of career paths and increasing job insecurity among employees add further complexity to the investigation of these links.
Methods
This study used a reflective methodology based on two previous scoping reviews conducted in Brazil11 and France14. The core objective was to analyze OHS policies by exploring strategies meant to overcome historical contradictions identified in each AS prevention network. These studies are part of a research project on the OADP in Brazil and France, which uses CHAT as the main methodological framework. Kick off meetings of both countries' teams were held to define similar objectives, research questions, types of reviews, criteria for screening, data charting, and analysis. One of the researchers participated in both reviews.
The Brazilian study followed the steps used for scoping reviews15,16. In this study, 64 texts were included. A worksheet was completed with the following categories of analysis: contradiction(s), type of contradiction(s), elements of AS involved in the contradiction(s), progress promoted by the contradiction(s), lingering limitation(s), identified runaway object, and additional observations11.
The French scoping review was mainly based on the same framework15,17,18. The final selection included 72 texts, and the data registered in a worksheet includes the instruments of OADP activity (subject, object, instruments, rules, community, division of labor), problem/conflicts, and hypothesis about contradictions14.
After finalizing the two reviews, and based on our findings, several round tables were held to analyze similar challenges faced by both countries and discuss strategies to overcome them, using the participants’ expertise and experience in this field (Figure 2). The analysis of this facing allows us the proposition of mediating elements for the development of prevention activity.
Results
The results of both reviews by summarizing the contradictions of both countries are presented below (Figure 3).
Our analysis identified that the above contradictions are the same for both countries, but they received different names. It was discussed how they are manifested in the decisions and practices of different AS for policymakers, companies, OHS services, public institutions, and representatives of social dialogue. The possibilities of facing the contradictions between economic and social growth were then discussed.
Primary contradiction for policymakers
One primary contradiction is the prioritization of policies for economic growth that do not consider the social impacts of such strategies. As large economies, Brazil and France espouse an economic model whose main primary contradiction is the tension between growth and sustainability. The proposed economic growth is not compatible with the objectives of sustainability, such as environmental protection or the protection of workers' health19,20. This contradiction is clearly evident in the neoliberal policies that aim to empty the state apparatus of regulation, licensing, and risk control. Additionally, neoliberal politics also aims to contest the budget allocated to social policies, allocating part of these resources to the privatization of services. Moreover, the contradiction is also quite serious in Brazil, concerning some public agents’ lack of autonomy to execute actions, regardless of the political and economic interference, as a political-ideological practice to overcome power relationships.
Furthermore, prevention means rethinking work systems, while repair is geared towards assuming responsibility for the failure of prevention. Managing consequences and their costs has been a subject of debate in France since the early 20th century. As the French parliament debated the first law on the recognition of work-related illnesses, some members of public authorities argued that workers had already benefited from financial compensation linked to the work-related risks, with a bonus that increased their salary. Since then, financial or organizational compensation for risks has been the subject of social negotiations between employers and trade unions21. In other words, compensation appears less as an object of social negotiation regarding the health consequences of working conditions and the societal acceptability of work-related diseases.
Economic policymakers face the challenge of accelerating economic growth and creating new jobs while, at the same time, ensuring social, environmental and health balance. Generally, they prioritize the first concern and leave the second aim as an issue of compensation or to be overseen by regulatory and supervisory bodies.
This primary contradiction intensifies and appears in other ways in policy formulation. Thus, the non-resolution of this primary contradiction promotes the emergence of secondary contradictions, most of which proved to be common between Brazil and France, as summarized above.
?
Primary and secondary contradictions for companies
The pursuit of immediate and higher profit through minimal investments, ignoring the sustainable development initiatives, as well as a lack of intervention in companies, is indicative of a financialization rationality. To meet the short-term income interests of shareholders, management devices have been introduced that encourage meticulous production processes towards achieving short-term results22,23. This process of financialization is based on the accelerated destruction of finite natural resources, the degradation of the safety conditions of the installations, and the deterioration of workers’ health. Effects such as deaths at work, premature aging, child labor, and slave labor begin to be seen as “externalities”, negative effects, but "necessary" for economic growth.
These management processes are supported by information technologies and other tools so as to achieve these goals. Instead of investing resources for serving the industrial safety or workers well-being, it essentially serves to increase the earnings of the few. These processes have been linked to the increase of precariousness and job losses, the emergence of “uberization”, the weakening of OHS, the increase in physical and mental illness at work, and the return of technological and environmental accidents.
Collective surveillance vs individual care for OHS services
In both countries, specialized services end up performing more care/individual activities to the detriment of surveillance/collective activities. The global economy itself promotes less regulation of markets and cuts in supervision. Brazilian public OHS services face their own dilemmas. They often dedicate themselves to "putting out fires" with individual care provided to victims of illnesses and accidents13,24,25,26,27. Other times, they conduct surveillance actions using specific instruments, such as medical monitoring, among others, which do not cope with an increasingly complex object. Work Organization Systems (WOS) are heterogeneous; they transform quickly, and the workers themselves constantly move from the formal to the informal sector.
In France, OHS services, led by physicians, play a pivotal role in the field of prevention. However, they also assume a dual role, serving as gatekeepers of controlling the workforce through medical examinations for fitness-for-work assessments21. For employers, the selection of workers by occupational health physicians represent a tool for the protection of their economic interests within the workplace.
Employment preservation vs working conditions for representatives of social dialogue
In the context of structural unemployment, the growth of informal work, along with more flexible employment policies and the liberalization of the labor market, trade unions, and other workers’ representatives , prioritizes demands. They develop an agenda more focused on job preservation and financial compensation provided to work-accident victims. As a result, they end up demanding specific short-term issues or tasks addressed to internal prevention committees within companies, external experts, or public OHS services13,24,28. In fact, this reflects the high degree of dependency placed on employers, who have the ability to push forward (or not) measures to the OADP29.
Interinstitutional articulation vs isolated actions
In France, two distinct risk prevention systems exist, yet neither simultaneously evaluate the same object for integrated policy formulation. This is related to a strict boundary between the inner risks of a company (which are matters of occupational risks) and its external issues (which are matters of technological risks). Brazilian authors point out that environmental and occupational risks are generated in the same production model30. These statements were identified in the two reviews and were highlighted as a contradiction between the environmental and the occupational risks, or as a contradiction in interinstitutional articulation. In other words, environmental and OHS policies are not fully articulated, despite the fact that the same model of economic development generates damages, such as environmental disasters and occupational accidents. Moreover, government funding incentives and tax exemptions for production chains ignore unhealthy and unsafe work process models. This illustrates a disarticulation between economic policy and social policy, which should include the protection and preservation of workers’ health.
This contradiction becomes even more evident in Brazil in the context of disasters, such as the Vale dam breaks, where the business model gives priority to value for shareholders at the detriment of maintaining safety structures31. The break in the Brumadinho tailings dam in 2019 resulted in the death of more than 270 workers and was the biggest environmental disaster in the country’s history. To date, no policy has been proposed seeking integrated regulation to protect safety and environment in the context of mining activity.
In Brazil, the advancement of OHS policies has been influenced by the WH approach, which is formulated with devices and instruments within public health services. Nevertheless, the OADP activity continues to prioritize actions over risk factors, yet it fails to consider actions over WOS. In France, this integration of WH within public health is not entirely clear and could be perceived as a contradiction in the intrainstitutional articulation.
The French review identified the contradiction between prevention and compensation policies. Prevention is a forward-looking process with a collective goal that requires the transformation of WOS, whereas repairing the harm caused to WH is assumed to compensate for the consequences caused to individuals without changing the model32. This has contributed to the invisibility of occupational accidents.
The documents included in the Brazilian review did not mention this fact, but its absence does not mean that it does not exist. The OADP activity of Brazil is indeed guided by prevention as a principle (instrument), but in the social security system, there are compensation mechanisms, such as the Accident Prevention Factor, regulated since 2009. This is a calculation applied to the companies' payroll, always based on the last two years of the entire history of accidents and accident records. Companies with a higher record of work accidents pay more on the payroll. Furthermore, This Prevention Factor was an attempt to promote better working conditions through a financial incentive, but this ended up encouraging underreporting. These individual compensation policies, as in France, weaken the principle of prioritizing collective prevention measures.
Finally, the Brazilian review found no manifestations of these contradictions at the level of company managers, but these are discussed by other authors23,33. Managers and decision-makers within production systems also face two paths. The first is that of short-term financial results to satisfy shareholders with high dividends, as explained above. The second is to create safe working conditions, ideally in negotiation with stakeholders, whose financial returns can be seen in the long term. However, when critical decisions must be taken, there is a system of financial incentives that promote the prioritization of production. Then, externalities are then considered by company managers, to be remote possibilities, and even if they do happen, they can be hidden or financially compensated. In the case of some occupational diseases, demonstrating the causal link with work is usually so difficult and time-consuming that companies carelessly assume the risks.
Discussion
With the advance of the neoliberal ideology within work organizations, deregulation put workers in a socially unprotected situation. Public policies focus on increasing employment (for a mechanical drop in the unemployment rate), with no correlation with the search for work quality and sustainability. The comprehension of sustainability includes identifying and questioning the variations at WOS, the management of those variations, their operative strategies, and how historically and socially the work was granted. In other words, the possibility of overcoming the contradiction comes with stakeholders’ perception of OHS practices to negotiate WOS from a new perspective34,35,36. In this section, we will discuss some implications that should be taken into account in the changes of public OHS policies in both countries, based on the recognition of the aforementioned contradictions and on the principles of prevention in public health.
The following challenges have been discussed because of their potential to mediate the analyzed contradictions in Brazilian and French OHS policies and practices: articulation between economics and social protection laws, making occupational accidents and diseases a public issue, focus on equity, the simultaneous implementation of both hard laws and soft laws, and the anticipation of policies.
Sustainability initiatives must also come from government economic policies. The need to mediate the contradiction of “social protection vs. job preservation” demands integrated and intersectoral policies. There is no point in seeking to accelerate economic growth and the creation of new jobs, based on measures that encourage informality and the precariousness of working conditions. Isolated labor reforms that promised to increase employment through "flexible" (or rather precarious) forms of work, in the medium term prove to be so harmful and costly for society that it may well be necessary to reverse them5,37,38. Therefore, the same relevance should be given to the quantity and quality of jobs generated. Legislators can implement these measures into effect whenever they feel pressured by public opinion. This macro-articulation must strengthen the interinstitutional articulation necessary for cohesive actions.
In both countries, despite the apparent decrease in workers’ accidents and diseases, new WOS hide a growing number of these events. These statistics, which seem to show positive results, among some government officers can generate a false sense of “situation under control” and that continuing with individual care actions is enough. One of the biggest challenges for OHS surveillance systems is to identify injuries that are work-related but that are not reported as such, including many traffic accidents and mental illnesses. This is especially true with the increase in informality and the loss of employment relationships, which end up making it difficult to design prevention strategies and to generate a high cost for public health systems in countries such as Brazil and France.
It is necessary to update policies in order to have explicit mechanisms to include informal workers, together with the detection, evaluation, and management of risks produced by new technologies, including unemployment and by new WOS. A pathway could be constructed from experiences of health popular surveillance actions39.
Since economies are global and governments are national, legislation is necessary but can be delayed; therefore, this information needs to be easily accessible to citizens so that consumption decisions are influenced by care criteria for workers. Alternative WOS that show more balanced results between profits and OHS also need to be more visible and encouraged within public policies23.
Furthermore, it is not enough to show how many accidents or injuries affect health systems. New surveillance instruments need to demonstrate the unequal impact on workers, depending on such aspects as income, gender, race, age, economic sector, and region. Critical epidemiology can contribute with its commitment to radical change and the development of ethics and rights40. This path can reveal the urgency of a wide range of prevention strategies in the diversity of new WOS.
Faced with the rapid transformation of WOS, the introduction of new technologies and new management methods, the need to update hard law OHS policies seems obvious. Moreover, as mentioned earlier, there are good OHS policies in both countries that have been difficult to implement. For example, in Brazil, there is already a system that allows primary care health professionals to notify health-related injuries to workers based on the consultations they carry out. However, the high turnover of these employees and, in some cases, poor training, mean that the notification, in public systems databases, does not happen properly. In addition, public agents experience problems in the implementations of policies and react to them in different ways, ignoring them, denying them, and attributing different meanings to them. To generate knowledge and transform prevention, a series of specific actions are needed, which move from the abstract to the concrete, that is, that lead to the revelation of a central contradiction in the development of activities, to the construction of a means through which to mediate contradictions, which can become a new form of activity41,42. In this case, soft law interventions are highly valued, which can help develop the implementation of a surveillance policy in a specific or more problematic location43. This is because the difficulties also vary between services and others, and it is necessary to stimulate interventions to help the practitioners of these policies.
The implementation of OADP, decent work practices, and sustainable development principles can also be subject to soft law research intervention44,45,46. The evaluation of these interventions can, at the same time, offer feedback to the formulation of hard law policies at a macro level (national) or a mega level (international).
Silently, complex systems are pushed to increasingly risky limits, creating all the conditions for disaster. Installation of new critical production or service processes would require OHS licenses, such as environmental licenses, in which companies undertake to place decent work at the center, proposing specific strategies for each situation beyond those mechanisms required by law. This type of anticipation device can help install protection mechanisms, especially in those production processes that are well-known for using repair compensations. Furthermore, surveillance systems need to facilitate channels through which to denounce situations in which serious accidents of broad impact may occur.
Conclusion
As the two largest economies, both Brazil and France have meaningful public health interests in the OADP. By developing OHS policies initially based on the same theoretical principles, both countries have made progress in the faster and better detection of “typical” risk occupational factors. Nevertheless, by transferring some higher risk activities from central to peripheral countries, the latter have taken the stance of controlling typical injuries related to strong industrialization processes. Through the emergence of new risks related to globalization's new forms of management, both countries face the challenges of accelerated transformation on the WOS and the difficulties of conducting surveillance for diseases and accidents that are related to work but that are not registered in that way.
Our reviews show differences in naming the contradictions, but our empirical data and historical analyses enable us to point out that the main contradiction for both countries continues to be related to the tension between economic growth and sustainable development. This primary contradiction, as long as it remains unresolved, has generated contradictions in the different AS responsible for OHS: governments, companies, OHS services, and trade unions.
As long as the same production-consumption economic model is maintained, the contradiction between growth and sustainability cannot be totally overcome. Decent work could promote the hubbing of the network of activities around the prevention and control of what we call here the runaway object. At the same time, it could mediate more sustainable and innovative management models seeking long-term results with less negative impacts on the environment and OHS. In the economic realm, the choice would be between a quick return with more predatory and risky activities vs. a slower return but more sustainable growth. In the social dimension, the choice would be between actions aimed solely at satisfying the needs of shareholders vs. more actions based on negotiation with stakeholders. The possibilities for changes in public policies highlighted herein can better deal with this tension, as they are strategies analyzed from the recognition of the resulting contradictions and public health prevention principles.
Acknowledgments
We acknowledge all insights and comments received from our colleagues in the ITAPAR research project.
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