Lack of occ-clinic access means emphasis on nurses

High-poverty areas far from specialty clinics

High-poverty counties in the southeastern United States have limited access to physicians and clinics specializing in occupational and environmental medicine, according to recent research, making the role of the occupational health nurse at workplaces in those areas all the more important.

"Access is always difficult in rural areas," says Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, president of American Association of Occupational Health Nurses (AAOHN) in Atlanta. "There just aren’t as many resources in those areas."

A study conducted by researchers at Morehouse School of Medicine in Atlanta looked at access to physicians and clinics specializing in occupational and environmental medicine (OEM) in the "cotton belt" region of South Carolina, Georgia, Alabama, and Mississippi, and the coal mining counties of eastern Kentucky.

What the researchers, including Lee S. Caplan, MD, MPH, PhD, found was that most minority and low-income workers in impoverished areas in the region studied are more than 100 miles from the nearest occupational medicine specialty clinic.

At the same time, many workers in these areas are working in the high-risk agricultural and manufacturing industries. "What the study showed is a significant shortage of board-certified OEM physicians and OEM clinics for disadvantaged populations in some areas," according to Caplan.

He points out that his team’s research, published in the March issue of Journal of Occupational and Environmental Medicine, shows that 95% of the population of counties in which at least 15% of residents are below the poverty level live more than 100 miles from the nearest Association of Occupational and Environmental Clinics (AOEC) clinic. AOEC is a network of NIOSH-funded clinics; the nearest clinics to the area studied are in Durham, NC; Nashville, TN; and Atlanta.

In addition from having limited access to specialized OEM clinics, only 17% of the counties studied had one board-certified OEM physician.

Caplan notes that census maps used for his team’s study suggested remnants of two historically important industries in the southeastern United States: cotton and coal mining. The areas with the highest concentrations of poverty and African-American population cut a path from the Mississippi Delta across central Alabama, Georgia, and South Carolina. In eastern Kentucky, similarly high poverty rates were noted in a region of high white population, reflecting the influence of the coal mining industry.

Both the agricultural cotton industry and the coal mining industry have been left behind as service industries and educated workers migrated toward urban industries, and it is there that more health care resource options — of all specialties — are easily found.

Randolph and Tee L. Guidotti, MD, vice president of the American College of Occupational and Environmental Medicine (ACOEM) and former president of the AOEC, say that part of the problem is supply and distribution.

"The fundamental issue, from the [ACOEM] view, is getting enough specialists out there who have the expertise to help," Guidotti says. "The southeast has been difficult for university programs, and clinics tend to locate in urban areas."

Randolph says that while the number of nurses in occupational health settings has grown overall in recent years, more are being outsourced through temp agencies rather than employed in-house, and that may be reflected in studies like the Morehouse paper.

"What this points to is the need to promote the specialty of occupational and environmental health, and ongoing education about what is an occupational health professional and when do you utilize those particular services," Randolph states.

In regions where access to specialized occupational health clinics is limited, she says, the value of an employer having an occupational health nurse on hand is clear.

"That’s where you will see the value of the occupational health nurse," Randolph points out. "The nurse may treat on site and use a physician with an occupational health specialty in the community. Or perhaps some of those illnesses and injuries can be treated on-site if the company has someone with those skills either on staff or with a temp agency."

And even if an OEM clinic is at a distance, because occupational health is an interdisciplinary specialty, an occ-health nurse is going to know where to refer a patient for advanced care.

"We tie into physicians because we are interdisciplinary and because there are some things beyond the RN’s scope of practice, so we need to have a relationship with physicians in the community," Randolph says. "It’s great if you can get someone who is board certified in occupational medicine, but in rural areas you’re not always going to have those kinds of resources."

And, she adds, "100 miles to a specialty clinic — that’s a couple of hours — is still a reasonable distance."

Researchers at Morehouse suggest medical schools cultivate more residency programs to train qualified OEM physicians, along with programs and incentives to place OEM physicians and clinics in underserved areas.

Guidotti says ACOEM has been concerned about the distribution of occupational health resources in the United States for some time.

"The most dangerous occupations in the U.S. seem to be progressively concentrated in most disadvantaged population," he states. "These people are getting less than they need, and the College has called for a more equitably distributed and increased supply of OEM physicians for years."

[For more information, contact:

  • Lee S. Caplan, MD, MPH, PhD, Associate Professor, Morehouse School of Medicine, Prevention Research Center, Atlanta. Phone: (404) 756-6673.
  • Tee L. Guidotti, MD, Vice President, American College of Occupational and Environmental Medicine; Professor, Chairman, Department of Environmental and Occupational Health, School of Public Health and Health Services, The George Washington University Medical Center, Washington, DC. Phone: (202) 994-1734.
  • Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, President, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. E-mail:]