Document gDn5kRzK1n7ZGR7mJr6JrRr0Q

I964 Pamnrzini Opation T h e Metamorphosis of Occupational Medicine to Environmental Medicine SE\V;\RD E. MILLER. XID, LOS ;\SCELES &bL->IEROCS \\-IDEL\7 diversified events earliest days. In recent years a fe\v of the ha1.e created renelvetl interest in inan`s response to his environment. 1-et the precise h i t s of man's tolerance for many en\-ironmental stresses are unknown. Medicine (particularly public health'),aerospace medicine, occupational medicine, industrial nursing, industrial hygiene, safety, engineering, and health physics are the health professions inost concerned. - i t the same time, social evolution impresses its more fortunate peoples on this earth have secured relative immunity from stan-ation throug-h improved methods of food production, preservation, storage, and distribution. Also these same groups of peoples now suifer much less from the ravages of infectious diseases through the application of environmental sanitation, personal hygiene, specific chemotherapy, and immunizations. alterations on our way of life. Thereiore, it seems desirable to examine these scientific Integration of Science into Medicine antl social forces in order to understand clearly our current situation. and then to peer for a moment into the future. First. let us consider some of the effects of environmental stress upon man. IVe all are aware of the great traversities man has suffered over the centuries from hostile forces in his environment. Long have the physical stresses such as heat, co!cl, and ambient atmospheric changes plagued man in his constant battle for existence. In addition, famine and infectious diseases have Ministering to the 5ick antl disabled by the ancient "medicine men," barbers, and early physicians was largely an art, for diagnostic tools were few, antl no specific therapeutic agents were available. IVith the development o i the biological sciences, medicine found a scientific ally. Quickly medicine embraced these new sciences that have contributed so much to our understanding of disease. Anatomy became more meaningful with an appreciation of the cellular structure of tissues. Physiology gave purpose to the multitude of diverse struc- been the scourge of inankind from his Submitted for publication June 21. 19fij; accepted July 9. From the Department oi Preventive Xredicine 2nd Public Hralth. School of Medicine. University o i California Xrecli. cal Center, Los .ingeles. Rend before the 19th Annual Rendevous of the Ramaz. zini Society, Sterling Forest. SY,Oct 9. 1964. Reprint requests to the Department oi Preventive JIedicine and Public Health, Scliool oi Lledicine. Untvers1ty oi California Xledical Center, Los ;\ngeles. Calii 00024. tures in the human body. Bacteriology shed brilliant light upon the etiology of some of man's inost feared enemies. Immunology, the sanitary sciences, and preventive medicine devised methods of eradicating o r controlling many infectious diseases. Pathology contributed a n understancling of disease Arch Enz,iron Hcailh-Vol 11, Dcc 1965 I I OCCUPATIOA'AL MEDICINE- MILLER 851 processes in all organs and body tissues. Much of this occurred only in the last century. It was inevitable that medicine should seek greater understanding of organ and cellular function. One of the physical sciences, chemistry, eagerly was embraced, and the science of biochemistry has flourished. Its contributions to our understanding of disease are well known. Moreover, in the development of specific chemotherapeutic agents. chemistry has added infinitely to the efficacy o i curative medicine. The other physical sciences were not far behind. I K t h the discovery of the properties of y-radiations, s-rays were harnessed as a diagnostic too1 and therapeutic agent. Safety engineering. industrial hygiene, and more recently, health physics emerged and joined the ranks of the health professions. During the first half of this century. so zealous became many physicians in practicinq scientific medicine and so enamored were they with the application of science, that in each patient they saw and treated cmly the diseased organ. Gradually a realization of the patient's need for something more than cold cataloguing, as a case of mitral stenosis or a cirrhotic liver, resulted in an appreciation for the need of embracing the social sciences into medicine. i n fac;. these vaLpe feelings were crystaliized by Dr. Christopher Leggo in the 19.;3 Ramazzini Oration entitled "Invite the Professor to Dinner." I n his inimitable facetious style, Dr. Leggo dramatically portrayed the need for medicine, particularly industrial medicine, to incorporate the concepts of sociology and psychology into its day by day practice. H e sounded a note since echoed back and forth across the land for treating the "whole man." In occupational medicine, some of the re&-'"-' niques of the social sciences have been utilized in counseling and dealing with socalled "well employees" to help them to a proper understanding of their work and home situation. As a result, much emotional stress has been alleviated, thus contributing to their productivity and happiness. But this is not all. Rehabilitation also has been developed by the successful application of a combination of social and medical sciences with the result that it has become standard practice in communities large and small. In addition, the concept has evolved that prevention, diagnosis. and treatment do not comprise the total field of medicine, but a fourth element. rehabilitation, is essential for the complete practice of medicine. Environmental Stress and Physical Sciences Recently, numerous developments have added impetus to our quest for more knowledce concerning the biological efiects of en- Arcit Enziron Hraltii--T~of 11. Dcc 1965 as2 0CCL;P44T I 0NAL M E DIC14VE--M I L L E R vironmental stresses. I will name only a few. The -1merican Medical -Association, in its reorganization a few pears ago, recognized the importance ot` environmental stresses in medicine by establishing a Division of Environmental Health that embraces occupational health, air pollution, aerospace medicine, industrial toxicology, and industrial hygiene. Still more recently, the XMX has created a new Committee on Environmental and Public Health. In 1960 the XMA changed the name of its specialty journal. ARCHIVES O F INDUSTRIAL HEALTH, to the ARCHIVES OF ENVIRONMENTAL HEALTH. and broadened its scope to preventive medicine, occupational medicine, and aerospace medicine. The American Physiological Society, in 1964, published the Handbook of Physiology, Szctiort J , rldaptatiolt to Eizvirotament, which is a monumental publication dealing primarily with the physiological effects of environment upon man. In aerospace medicine there has developed a crucial need for precise knowledge of the extremes or limits of man's tolerance for many of the physical stresses in our environment. Two ol the more troublesome biomedical problems are the oxygen content and air pressure requirements of the atmosphere for prolonged periods of inhalation, and man's reaction to prolonged decreased air pressure. Currently astro- nauts are being given lOOqr0 oxygen at 5 Ib per square inch during ffights, and this is the atmosphere planned for the Apollo space craft cabin. Other environmental stresses of concern include abrupt intense temperature changes, ionizing radiations, toxic chemicals, and the limits of G force in acceleration and deceleration that can be sustained without body or tissue damage. Also, the biological effects of sustained lack of gravity, although not established, are believed to vary from muscle weakness to the decalcification o f bones and the loss of blood fluids. These and many other aerospace medical problems have further accentuated our need for more precise knowledge con- cerning both the immediate and long-term effects of the physical and chemical environ- mental stresses on man. In addition. .lie intensity of the psychic .;tress and man'- ,)I- erance fur this neetls to be equated. Exploration ot` the lierp sea in orriel- t o exploit its riches has been a long-time dream of man. The 1964 development of a onethousandth-inch-thick periect polymer membrane, that permits osygen from sen Ivater to pass through quickly and carbon 1 liositle to diffuse out, is a significant new device to aid man in his conquest ( ~ tfhe deep sea. The ill-fated Keller deep sea diving demonsrration with the loss of two lives OR Catalina Island last year, and indeed. new techniques in deep sea diving and unique equipment for "housing" man on the ocean bottom for prolonged periods, have caused reexamination o i man's reaction to the environmental stresses of increased pressure, oxygen consumption, carbon dioside disposal. and resistance to cold. Preventive medicine, and particularly that developing new area denoted by the term "community health," now recognizes need for knowledge beyond communicable diseases, maternal and child health. sanitation, and the social sciences in dealing with new emerging community health problems. Some of these community environmental stresses have created definite health problems, while others are feared as detrimental to health, but no health problem has been established. Air pollution, water pollution (chemical), vibrations, noise, and intensity of electromagnetic radiations, including ol course the various wavelengths of light, are among the physical and chemical stresses causing con- cern to community health authorities. To ... cope with these entities, the Public Health _ ' Service and some state and local health de- partments have established Environmental Health Bureaus o r Divisions employing in- dividuals particularly skilled in the physical, chemical, and biomedical sciences. .: - The sciences of physics, engineering, a d , physical chemistry have produced in recent years many astonishing new concepts. So?: have forced themselves into medicine and industry, while others are being examined f o r possible application by industry and medicine. Ionizing radiations and radioac- Arch Environ Hcaltli-Vol l I , Dcc 1965 OCCUPATIONAL MEDICINE- MILLER 853 ive isotopes are extensively used both in ndustry and in medicine. Cryogenic mate~ a l hsave found wonderous uses in industry tnd medical research with further applicaion in medicine to be expected. Cryogenic iquid hydrogen and oxygen are used widely n rockets and space vehicles. Maser, an acronym standing for Molecuar -4mplification by the Stimulated Emission of Radiation, and Laser, also an 3cronym standing for Light Amplification b!- Stimulated Emission of Radiation, are seing investigated extensively by industry. They pose significant health hazards. The 3bility to excite electrons into higher orbits ibout the nucleus of certain atoms and the harnessing of this energy as in controlled Laser emissions staggers the imagination with its possibilities in communications and as sources of intense energy, particularly pinpoint heat. In addition, it is becoming clear that the full long-term biological effects of these radiations are as yet unknown. Lastly, permit me to mention the physical chemical phenomenon of Clathration. In- vestigation of the physical structure of molecules has revealed many variations in the configuration of molecular structure. Curiously enough, molecules are far from compact solid structures. It turns out there are inany holes of various shapes and design in the structure of molecules. Some molecules have a latticework structure while others have well-defined tunnels running through them. By intricate physical chemical means, the diameter of these open spaces has been calculated for some materials. This would be scientifically interesting, but irrelevant to our discussion were it not for the fact that certain gaseous atoms, under appropriate circumstances, can be forced to enter these spaces and reside there. They literally become trapped in the latticework or tunnels when there is a tight fit. blolecules supplying the hole or space are called the host, while the gaseous atoms taking up residence in these spaces are termed guests. X o chemical bond exists in this situation. The guest atom apparently is held in position by attraction between the electrons in the outer orbits of the atom and those electrons composing the inner surface of the cavity in the host molecule. Amazingly the chemical properties o i such substances become exclusively those of the host which remains unaltered by the acquisition of these guests. The chemical properties of the guest atoms disappear completely until these atoms are released by physical or chemical means from their abode in the host molecules. The Clathration technique now is being utilized by the petroleum industry in removing certain objectionable paraffins from high grade oils. Another current use lies in capturing and holding molecules of the so-called noble gases: argon, neon, krypton, and xenon that are practically inert chemically. Other wide industrial applications are anticipated, and the possible use of this phenomenon in medicine appears likely. First the biological sciences, then biochemistry and the social sciences, have contributed greatly to the ability of medicine to serve mankind. Kow physics, engineering, and the physical sciences are coming to the fore. Biophysics and bioengineering not only are bona fide fields of endeavor, but trained individuals in these fields are in demand to work on most exciting projects in connection with man's conquest of space, the atom, the deep sea, or to assist in the reshaping of our cominunities by the application of environmental health science and technique. At least one of the nation's major universities has de\-ised a new graduate area of instruction. bioengineering, to help meet the need ior trained individuals in this new aspect or' Environmental Medicine. These are some of the forces contributing the tools and the technical know-how for medicine to s e n e the growing and changing needs of mankind better. Yet. curiously enough, these startling scientific forces are not the dominant factor in shaping the changing pattern of medical services, particularly of occupational medicine. The most potent force by far operating relentlessly in reshaping the pattern of medicine, and especially occupational medicine, is social evolution. Arch Environ Health-Vol 11, Dec 1965 Social Evolution Curiously, social evolution has determined the present character of occupational medi- cine to a far greater extent than has tech- nical and scientific know-how. Moreover, there is every indication that it will continue to do so. Let us turn for a moment from the intriguing technical considerations we have been dealing with, to take a serious look at social evolution of this century. Place it along side current scientific progress and on this basis appraise the metamorphosis occurring in occupational medicine. At the turn of this century, no occupational health services, as such, existed on this continent. There was technical. engineering, government agencies for protection from death and disability accruing from the work environment. In response to this social ex- + pression, in 1913 two of the more inindustrialized states, Ohio and New York, established the earliest official state occupational health programs, or as they were then --called. industrial hygiene programs. Shortly thereafter, state labor departments began developing industrial accident prevention programs and factory inspection services. scientific, and medical knowledge to operate broad occupational health and safety programs commensurate with the industrial technoloyy o i the day. But no such services were present either i n industry or in government agencies. The few nurses and physjciaiis then employed by industry in --c isolated lumber camps and mining communi- Social concepts continued to grow, and in 1935 the Social Security legislation was enacted. However, in 1935 only selren states had official industrial hygiene programs. Funds for support of state and local health agency services then became available under the Social Security Law. Through the stimulation provided by the Public Health . ties &ere engaged full time in the practice of -&curative SFidicine, totally oriented to the treatment of the sick and injured. Overt prevention of occupational diseases or traumatic injuries was not practiced. N o form Service and using the general public health state grant funds, 23 additional states initiated industrial hygiene programs as part of the expanding services of their state health departments. of what we currently term occupational Present Social Trends.-Social progress health and safety existed. did not cease with the passage of the initial Partly because of the wanton and flagrant Social Security legislation ; in fact, the pace disregard for human life and disability by of social evolution has accelerated rapidly, the hard-hitting industrialists of the day, workmen's compensation and insurance legislation came into being early this century. Industry was forced to accept responsibility particularly during the past two decades since World War 11. As a result, today 4 4many social changes are in prospect that will -- result in sweeping alterations in occupa- for those employees killed, injured, or disabled in the course of their employment. Then, for the first time, industrialists engaged physicians to render in-plant medical services particularly pre-employment examinations weedinq out all except the most physically perfect applicants. Safety engineering as a profession emerged, and industrial nursing came into being. Eut what was the basic force that caused the enactment of the workmen's compensa- tional health services. It may be argued that the public does not have the technical background or scientific know-how to decide what is best, and that these problems are scientifically too complex for the public to resolve. Therefore, upon this basis, all decisions as to the amount, type, and technical content of occupational health services. and how best to execute them, can be planned and carried out by 1 tion legislation? It was the result of the health scientists and technically trained evolution of the social conscience of the personnel only. This line of reasoning, a]day. For the first time, there had developed though attractive, is nonetheless fallacious. - Arch Environ Hcalth-Vol 11, Dec 1965 ,5, i 11, i!, I?C, :,! 1)l I" * Ii <r" I"-. ii:' i, ) ' \\-I tic'' 111' 1)I 3 ' ['I,' 11;i OCCUPATIONAL MEDICIIVE-MILLER 855 l:or although labor, the workers, do not know the technical means of achieving what they want, they can express precisely their desires. Simply and broadly stated, these consist of the following: 1. Workers do not want disease or disability to accrue to them from the work environment; that is, they demand a safe healthful place in which to work. 2. When taken ill or injured, workers want immediate expert medical care without protracted arguments or delays over which insurance, workmen's compensation, or group health insurance is to care for them and pay their bills. 3. When disabled, workers want assurance of a continued income for their own protection and that of their families, again without delay, and for certain they do not want to pay half, or any portion, of the paltry disability compensation to a lawyer in order to secure for them what is rightfull!* theirs. The working public knows what it wants and is beginning to perceive clearly how to get it. It is by social legislation that workers and their leaders hope to achieve these objectives. I t is being contended that support for the disabled should come from industry no matter what the disability, or where or how it is incurred. In recent years this enlarged social concept has been the motivating force in greatly expanding workmen's compensation awards to cover death or disability from heart disease, cancer, mental illness, and so forth-disabilities usually not arising out of and often not in the course of employment. This socioeconomic philosophy, that it is preferable for each industry to support its own regardless of the etiology of the disability than for conimunity welfare services to do so, when carried to its logical completion, and this now is in progress, ultimately can result only in further broadening of the Social Security legislation to cover all disability, partial as well as total. and temporary as well as permanent. Moreover, expansion of Social Security to cover all disabled individuals is to be anticipated because there will be many disabled who are not employed by industry, and social legislation is coming to be all inclusive rather than simply desiLpating benefits for specific groups. Xext let us examine another social dei.elopment that is gaining momentum in this countn, specifically the problem of providing for the disabled. Socially it is no longer acceptable, and happily so, that the disabled and their families be relefated to various community welfare rolls and forgotten. The Social Security Act n a s amended a few years ago to provide disability retirement for those incurring total permanent disability before age 65. In addition. vast sums of money have been spent by federal and state rehabilitation prozp.ms in an attempt to return disabled individuals to the active productive work force of the nation. Eased on the arLpment that a disabled worker has given his all in serving a particular industry. the social concept that industry. not public welfare, should support him has been yaining favor in social planning circles. Moreover, this concept ha3 been espandetl to cover all disability. A t the same time, another facet of social evolution lies in providing medical care for those over age 6.5 under Social Security. 116th the death o i Senator Kerr, who was the dominant iorce behind the Kerr-Mills Act. and the man who was credited with defeating President Kennedy's plan for Xedical Care for the Aged under Social Security, one could have predicted that medical care for the aged would pass the Senate as it did in 1964. Likewise, it can be predicted that in 1965 at President Johnson`s insistance, this legislation along with certain other changes in the Social Security law will be enacted by the Conqress. The amended Social Security ;ict will provide complete and free medical care. although with some limitations. for all citizens over age 65 whether or not there is financial need and whether or not the individual ever has worked under Social Security coverage. Now when medical care f o r all over age 65 under -4rcIi Enziron Health-lz-nl 11. Dcc 1965 Social Security becomes a reality, there is assay these vexing and complex problems % every indication that the Social Security and to establish clearly the role of environ- 2 Act further will be extended by great mental stresses in connection with the de- "- socioeconomic-political pressure to cover velopment of overt chronic degenerative -; total medical care. Perhaps at first this will disease. T be only for workers and their families cov- Let me present one example. that ot' vered under Social Security. but ultimately the chronic pulmonary disease problem, every individual will be eligible to receive chronic bronchitis and enlphysema. complete medical care under some type of Chronic bronchitis has become so unii ersal government-sponsored medical care program. Whether we as physicians and health scientists like it or not, and whether such legislation will produce the best medicine for our people or not, this clearly is in Great Britain that it has been charac terized as a national disease. Earlier it was popularly ascribed to the numerous dusts, vapors, fumes, and irritant gases so prevalent in many o i the older industrial work- the trend of social evolution. It represents ing environments. Just a iew years ago a the application of socioeconomic and socio- painstaking, detailed. epidemiological study political measures by the people in the comparing British workers antl their wives hope of resolving pressing health and health-economic problems of the day. It appears inevitable that it will occur despite the ..-r well-organized conservative groups who oppose . such developments. The course o i social evolution presses on relent- resulted in the surprising finding that the wives. who had experienced little of the (lusts, gases, or fumes of the industrial work environment, nevertheless had as much chronic bronchitis as their husbands. More recently the TjS Surgeon General's Iessly. report on smoking stated repeatedly that Current Twnds in Occupational Medicine.-Let us now examine in greater detail 'our growing concern with environ- smoking was more causatively related to the development of chronic bronchitis and emphysema than the work environment. mental stresses and how they affect the I n this country, in the male. chronic practice of occupational medicine. bronchitis too frequently is followed by the T o begin with. so efficient have our industrial hygiene, safety engineering, and medical controls become that new cases of frank occupational diseases are comparative rarities, and workers also are safer from traumatic accidents at work than on the highways or at home. In medical centers we no longer easily are able to find cases o i overt occupational disease to show our students. Today the growing concern of many social planners and scientific researchers lies in the long-term effects of environment on longevity and disability. Are there work or community, or combined work and community environmental stresses, that aggravate or early precipitate the onset and hasten the cievelopment of cancer, heart dis- gradual development of emphysema. Once emphysema becomes full-blown. the victim is a pitiful object. Day and night he is gasping for breath and holds on to life tenaciously by a most slender thread. They are the "short of breath" patients who today have been kept alive to reach this miserable plight by miracle drugs antl antibiotics. Heretofore, most of these pulmonary (cripples afflicted by recurrent respiratory infections were carried away long before they reached the terminal stages of emphysema. Currently the ranks of the chronic pulmonary patients, particularly those with emphysema. are swelling daily while physicians and health scientists stumble around fumbling for an explanation, but not know- ease, or any of the inany chronic deqenera- ing how to go about preventing this rising tive diseases? New types of epidemiological title of disability. Once the unhappy victim environmental stuclies with broad epidemio- of chronic emphysema becomes totally dis- logical bases must be devised and executed to abled, i f employetl, he invariably can recall Arch Environ Ncalth-Vol 11, Dec 1965 i OCCUP=1TIONAL MEDICINE- MILLER 837 esljeriencing a work environment laden with dust or an irritant vapor mist or gas. H e frequently attributes his disability to such a Lvork exposure while the specialists in this Social Security, or some similar form of compulsory health insurance, government sponsored, and that all forms of disability will be under Social Security. area are unable, uniformily and with certainty, to equate the relationship between the disability present and the past work or community environment. Constantly physicians are harassed by questions regarding the significance of cigarette smoking, genetics, various work environments, and community air pollution in relation to the development of chronic bronchitis and emphysema. In this situation, occupational medicine is in a most uncomfortable and untenable position. The failure of occupational medicine to produce the answers to this and many other health problems of older workers lies partly in the f ragmentation o i medicine and.partly in the "state of the art." The narrowness of the base on which occupational medicine operates, ie. the work environment of the eight-hour work day five days a week, while largely ignoring the influences of community environmental stresses accruing in the other 16 hours a day and 128 hours a week, manifestly make solution of these probleins impossible for occupational medicine. Herein lies one of the potent forces pushing for the expansion of occupational medicine to total environmental medicine. T h e F u t u r e of Occupational Medicine LTnder these circumstances a gradual SUCcession of changes in occupational medicine during the next 50-75 years is inevitable. Logically, it iollows that all present state workmen's compensation legislation will become obsolete. Also all private forms of workmen's compensation insurance will disappear when all medical care and disability payments are under government auspicies. The entire voluntary health insurance system, and most, if not all, group health insurance plans will be doomed when government-sponsored complete medical care for everyone comes into being. Obviously, this state of affairs will be reached only af ter long sociopolitical effort accompanied by much anguish. Also, it will come about bit by bit, permitting time for adjustment of current programs to the newly created circumstances. Gradually then, there will evolve marked changes in the practice of medicine with a new format for occupational medical services. Permit me to list some of the major points: 1. Personal preventive medical programs of the occupational health type will be extended to coirer all members of the community. Trained occupatiocal medicine physicians will operate broadly in the community as well as in plants in cooperation I:\J;hat then of the future of occupational medicine ? Let us assume that 1) biophysical and bioengineeriilg knowledge continue to gron-. ( 3 ) man n i l 1 sustain increasing physical, chemical. and psychological environmental stresses in his work and com- munit!-. ( 31 overt occupational disease and in.iurie5 continue to decrease, 13) employer.. workers. and health and social scientists all continue their demands to know the lony-term effects o i various worli ant1 community em-ironmental stresses on hea!th. (`5 I social chanyes will continue. that society will not become frozen as is, and ( 6 ) inevitably compiete meciical care for employed worker; and their inmilies will be under with local cominunitJr health services. 2. T h e retained in-plant health and safety programs will be oriented largely towards the specific health hazards of that industry with emphasis on safety, first aid. health education, and counseling. Special examinations will be accorded various groups of workers incurring specific exposures. Improved health maintenance programs for groups of workers will be integrated with community health maintenance programs. I-Iowever, human relations problems will be the chief concern. ior numerically, they will zreatly exceed physical injury and occupational disease. Arch Environ Hcalth-J/-ol 11. U S C1565 I 3. Pre-employment physical examinations, or as today we euphemistically term them, pre-placement examinations, will be redesigned not only to identify those physically fit for employment, but also to serve as sound base-line health audits primarily for health maintenance purposes. Placement of those medically tit for employment will be made largely by psychological aptitude and personality testing in the personnel department. This will be based upon the con- cept that every industry or business, or both, must employ its portion of the cross section of the community. 4. Insurance companies as a source of industrial health services. particularly safety. industrial hygiene, toxicology, medical. and nursing consultation services. will disappear. 3. More and more. small industry will come to rely on oficial agencies for such routine services as the following: (1) industrial hygiene, 12) advice and counsel on builtling proper controls into all new construction and all remodeling, ( 3 ) industrial accident prevention services, (4) advice on evaluation and control of all types of environmental hazards, chemical, physical, psychological, and traumatic, and ( 5 ) p h y s s a n and nurse . consultation services. 6. I n the continuous reorganization of health agency functions, the official occupational health programs are destined to become broad sanitation and environmental health programs. Inevitably, government occupational or environmental health programs will become closely aligned with the growing chronic disease control programs now sponsored under community health services. 7. In such an era the communities them- selves will come to be regarded as complex industrial organizations from a health and epidemiological point of view. The longterm complex epidemiological studies of the influence of all the various environmental stresses on health will require total environ- A- mental orientation. ie, both industrial ,ind community. 5. Inevitably the technical ;ntlustrial hygienist must become an expert. !veilrounded, total, environmental hygienist. The industrial safety engineer also must become a broad environmental safety engineer. The industrial physician, toda!- preoccupied with the health of only one group of employees, will become a specialist in total community environmental medicine as well as occupational medicine. Industrial nurses also will become more closely integrated with preventive community health nursing. Such physicians and nurses will promote and coordinate adult health maintenance programs with close integration of chronic disease control and expanded rehabilitation services. Not rehabilitation directed and oriented primarily toward reemployment as is so highly emphasized today. but rather rehabilitation aimed at achieving maximal self-care and enjoyment of living for every disabled individual. 9. Industry will demand and employ more and more sophisticated bioenvironmental and bioengineering specialists to work side by side with design engineers and creative scientists inside its research laboratories. The metamorphosis of occupational rnedicine to environmental medicine then will be complete. Let me stress that we as in- dividuals can do little either to accelerate or delay social evolution, but we can do much toward accelerating the development of scientific environmental medicine. Of par- ticular import to environmental medicine are those new concepts, both social and scientific, affecting the character of occupational medicine and the development of integrated community environmental health programs. To paraphrase from Dr. Christopher Leggo, "Invite Environmental Physiology, Bio- engineering, and Biophysics to Dinner." I only wish he had atlderl-"And Fear Not, Social Evolution." A r c h Envtron Hralth- Vol 11, Drc 1965 - d- _ -