OCCUPATIONAL HEALTH IN

INDONESIA

AN OVERVIEW

Astrid Sulistomo
Dep. Of Community Medicine
FMUI
 Curriculum Vitae

Name : DR. Dr. Astrid Widajati Sulistomo, MPH, SpOk

Staff of Community Medicine Dep FMUI
EDUCATION:
Medical Doctor – University of Indonesia, 1976
MPH (Occupational Medicine – , University of Michigan, 1994
Occupational Medicine Specialist – MKKI, 2003
Doktor (PhD) – University of Indonesia , 2008

CURRENT POSITION :
Director of University Clinic UI
Secretary of Occupational Medicine Specialist Program
Chair of CME Division Indonesian Associatio and College of Occupational Medicine
Specialist

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 SCOPE OF PRESENTATION
• Background
• Worker population
• Problem statement
• Occupational Health
• Laws and Regulation
• Competencies in Occupational Medicine

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 BACKGROUND
• Indonesia as the largest archipelago in the
world, is also known as a country with plenty
of natural resources.
• In the last decades industry has developed
rapidly - in all sectors (mining, manufacture,
agriculture, transportation)
• Remote areas that are underdeveloped also
are affected by industrial development

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 CURRENT SITUATION IN INDONESIA
Population : 237,556 million

BPS , data Febr 2013 :

Unemployment Rate 5.92% (7.17 million)

2.569.400 Formal industries

160 Industrial estates in 13 provinces

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 CHARACTERISTICS OF WORKERS:
• 50% of the Indonesian workforce had only
elementary school education
• Only 8% of the Indonesian Workforce have
an Academic/University degree
• www.fiskal.depkeu.go.id
• Prevalence of common diseases: Infection
and undernutrition is still high
 50% work in agriculture, forestry and fishing
– sectors with highest risk
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 PROBLEM STATEMENT
• Based on reports by PT
Jamsostek, in 2012:
103.000 work related
accidents occurred - an
increase from previous
years
• 9 work related deaths
occur daily
• 25 disabilitis per day

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 Problem Statement (2)
• Those figures are based on reported cases –
underreporting is still high
• Occupational Disease (?)

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 PROBLEM STATEMENT (3)
• No representative
national data exist on
Occupational Diseases
• Studies on
Occupational Health
problems in Indonesia
are still limited
• Human Resources in
Occupational Health are
still limited

8/23/2017 OH in INDONESIA AS 9
 Prepared by Dewi Soemarko, modified
23/08/2017
Dina D (Juli 2015)
10
 Prepared by Dewi Soemarko, modified
23/08/2017
Dina D (Juli 2015)
11
 OHS PROGRAM
• Since 1970, implementation of OHS
program by industries is mandatory by
Law no 1/1970 on Safety at work

• Regulates about safety at work

• Regulates to have an OHS team at the
workplace
• Primary Prevention at the workplace

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 OCCUPATIONAL HEALTH
• Occupational Health is the promotion and
maintenance of the highest degree of physical,
mental and social well-being of workers in all
occupations by preventing departures from
health, controlling risks and the adaptation of
work to people, and people to their jobs. (ILO /
WHO 1950)
• OH deals with all aspects of health and safety in
the workplace and has a strong focus on primary
prevention of hazards. (WHO)

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 OTHER OH DEFINITION
• Occupational health and safety is a cross-disciplinary area
concerned with protecting the safety, health and welfare of
people engaged in work or employment. The goal of all
occupational health and safety programs is to foster a safe work
environment

• Components of Occupational Health:

– Occupational Medicine, Industrial Hygiene,
Occupational Health Nursing, Ergonomi,
Industrial Toxicology, Industrial Psychology

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 Relationship of OHS Professionals

INDUSTRIAL HYGIENIST

Sources
OH – DOCTOR & NURSE
SAFETY OFFICER
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 8/23/2017
DOKTER DI BIDANG KESEHATAN KERJA DI
INDONESIA

• Dokter + pelatihan Hiperkes ( 2 minggu ) dan pelatihan

di bidang kedokteran okupasi lain
• Dokter + Magister Kedokteran Kerja (+ 460 orang)

OH in INDONESIA AS
• Dokter + Magister Kesehatan dan Keselamatan Kerja
(manajemen program K3)
• Dokter Spesialis Kedokteran Okupasi (+180 orang)

• Kebutuhan akan dokter yang dapat memberikan

pelayanan Kesehatan Kerja masih sangat tinggi
16
BIDANG ILMU KEDOKTERAN (AIPI)

Kedokteran

Biomedik Klinik Komunitas

Medik Bedah

Kedok keluarga,
Kimia fisika, kedok okupasi,
biologi, biokimia, Interna, anak, bedah, obgyn, rehab medis, kedok Olahraga,
dll dll dll

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 RELATED REGULATION

Basic Law 1945:

Every Indonesian citizen has the right to a decent
work
Law nr 13/2003 on workers:
Each worker has a right to be protected
Law nr 36/2009 on Health
Regulates scope, responsibility and duties od
government, employer and workers to protect
workers health

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 OTHER RELATED REGULATION
• Presidential Letter of Decree RI 22.1993:
– 31 Diseases caused by work that are
compensable
• Regulation of Minister of Manpower 2/1980
– Required to do pre-employment, periodic and
special health examination
• Regulation o Minister of Manpower
01/1980
– Manadatory to report occupational accidents
and diseases

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 • Regulation of Minister of Manpower 03/82
– Regulates about OH services
• Regulation of Minister of Mining and
Energy 555 K/26/M/PE/1995
– OHS Team in each oil and gas industry
– OHS Training or all supervisors
• Distribution letter and Regulation of
Minister of Manpower 01/1997 and
51/1999
– TLV of Physical and Chemical Hazards
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8/23/2017 OH in INDONESIA AS 21
8/23/2017 OH in INDONESIA AS 22
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 ICD 10 - OH

Prepared by Dewi Soemarko,

23/08/2017 24
modified Dina D (Juli 2015)
 Penyakit Akibat Kerja
• ILO Convention No. 121 di Geneva pada December 1991  Penyakit karena agen,
penyakit sesuai target organ dan keganasan

• ICD 10 – OH , secara umum dibagi menjadi:

1. Diseases caused by agents
1.1 Diseases caused by chemical agents
1.2 Diseases caused by physical agents
1.3 Diseases caused by biological agents
2. Diseases by target organ
2.1 Occupational respiratory diseases
2.2 Occupational skin diseases
2.3 Occupational musculoskeletal diseases
3. Occupational cancer
4. Others

Prepared by Dewi Soemarko,

23/08/2017 25
modified Dina D (Juli 2015)
 OCCUPATIONAL HEALTH SERVICES

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 SASARAN PROGRAM KESEHATAN KERJA :

1. Komunitas dan individu pekerja

2. Komunitas di sekitar lingkungan tempat kerja.

27 8/23/2017 Pelayanan Kedokteran Okupasi - A.S

 PELAYANAN KESEHATAN KERJA

• Fokus :
– pengaruh pekerjaan terhadap kesehatan :
• Penilaian risiko potensi bahaya
• Pencegahan Penyakit Akibat Kerja
• Diagnosis Penyakit Akibat Kerja

– pengaruh kesehatan terhadap pekerjaan:

• penilaian apakah pekerja masih laik kerja
• upaya rehabilitasi agar pekerja dapat kembali
bekerja.

12/12/2012 Pekerja Kereta Api AS 28

 PELAYANAN KESEHATAN KERJA
• PELAYANAN MEDIS:
– Pelayanan yang diberikan dokter, dibantu oleh
tenaga kesehatan lain

• PELAYANAN NON-MEDIS:
– Promosi Kesehatan
– Pengendalian Lingkungan Kerja

Pelayanan Kedokteran Okupasi -

8/23/2017 29
A.S
 PELAYANAN MEDIS :
• Pemeriksaan Pra kerja
• Pemeriksaan Berkala
• Diagnosis Dini Penyakit Akibat Kerja
• Diagnosis dan Penanganan PAK/KAK
• Fit to Work
• Return to Work Evaluation
• Penentuan Kecacadan & Perhitungan
Kompensasi

Pekerja Kereta Api AS 30 12/12/2012

 HUBUNGAN KESEHATAN PEKERJA
DENGAN RISIKO KECELAKAAN

A
IMMEDIATE CAUSES
C
C
UNSAFE ACTS I
RESULT
D
UNSAFE CONDITIONS E
N
CONTRIBUTING CAUSES
T

SAFETY MENTAL PHYSICAL

MANAGEMENT CONDITION CONDITION
PROGRAM OF WORKERS OF WORKERS

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31 Pelayanan Kedokteran Okupasi - A.S
 STEPWISE DEVELOPMENT OF OHS
(ILO/WHO 2005)

Pelayanan Kedokteran Okupasi -

8/23/2017 32
A.S
 STANDAR KOMPETENSI DOKTER
INDONESIA 2012
• Melakukan diagnosis penyakit akibat kerja
dengan 7 langkah diagnosis okupasi – level 4

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 KOMPETENSI SPESIALIS
KEDOKTERAN OKUPASI

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 STANDAR KOMPETENSI DOKTER SPESIALIS
KEDOKTERAN OKUPASI

A Kompetensi Umum
1 Aspek medikolegal, etika, dan perundang-undangan dalam
kedokteran okupasi
2 Komunikasi dalam bidang Kedokteran Okupasi
3 Keselamatan Pasien dalam Kedokteran Okupasi (Patient
Safety)
4 Kerjasama Tim dalam bidang Kedokteran Okupasi

Prepared by Dewi S
Soemarko ( 29 Aug 2014)
35
B Kompetensi Dasar
B.1. Kompetensi Utama
1 Mampu melakukan surveilens medis pada komunitas
pekerja (Occupational Medical Surveilance)

2 Mampu melakukan penatalaksanaan dan penanganan

Penyakit akibat Kerja secara komprehensif termasuk
penentuan Diagnosis Okupasi
3 Mampu membuat penilaian laik kerja (Fit to work)
pekerja
4 Mampu melakukan evaluasi dan mengembangkan
program kembali kerja (Return to work)

5 Mampu melakukan penilaian kecacatan dan

perhitungan persentase kecacatan akibat kecelakaan
kerja atau penyakit akibat kerja
 B.2. Kompetensi Penunjang
1 Mampu merancang dan melakukan pemeriksaan Kesehatan
sebelum kerja dan berkala serta khusus pada pekerja dan komunitas
pekerja sesuai dengan karakteristik pekerja, jenis pekerjaan dan
pajanannya
2 Mampu melakukan analisis dan menyimpulkan hasil pemeriksaan
kesehatan kerja secara individu dan kelompok serta membuat
rekomendasi yang mampu laksana
3 Mampu merancang dan melaksanakan program promotif dan
preventif dalam bidang kedokteran okupasi dan kesehatan kerja
4 Mampu melakukan pendidikan dan komunikasi efektif dalam
bidang kedokteran okupasi
5 Mampu mengembangkan dan mengelola program K3 dan
kedokteran okupasi di tempat kerja yang sesuai dengan tingkat risiko
6 Mampu mengidentifikasi faktor risiko dan bahaya potensial di
tempat kerja maupun lingkungan di tempat kerja yang dapat
mempengaruhi kesehatan individu pekerja dan komunitas
(masyarakat dan komunitas sekitarnya )
7 Mampu melakukan identifikasi pajanan di tempat kerja dan penilaian
serta pengendalian pajanan di tempat kerja (manajemen risiko)
8 Mampu melakukan analisis tugas kerja di perusahaan (Job analysis
pekerja).
9 Mampu mengimplementasi prinsip-prinsip
toksikologi industri pada pekerja dan komunitas
yang terpajan.
10 Mampu mengaplikasikan aspek psikologi kerja
1 Mampu
dalam melakukan
menunjang analisis penatalaksanaan
keputusan dampak bahaya
1 lingkungan
masalah kerja bagi
kesehatan kerjapekerja dan masyarakat
sekitar
1 Mampu melakukan penelitian sesuai kaidah ilmiah
2 dalam bidang kedokteran okupasi
1 Mampu menganalisis kebutuhan gizi komunitas
3 pekerja
1 Mampu melakukan analisis dan pencegahan
4 kecelakaan kerja secara komprehensif
1 Mampu melakukan dan atau menilai uji latih
5 kapasitas paru dan kardivaskuler untuk penentuan
laik kerja (fit to work).
16 Melakukan dan atau menilai pemeriksaan untuk menilai
pajanan, menunjang penegakkan Diagnosis Okupasi
/PAK dan evaluasi pajanan serta penentuan laik kerja,
yaitu pemeriksaan
- biomonitoring
- spirometri Okupasi
- audiometri Okupasi
- ILO RAdiografi
- Uji Latih Kapasitas Paru dan Kardiovaskuler
- Pemeriksaan lainnya yang sesuai (lakasidaya reaction
time,
Mampu Lantonine test,dll)
melakukan pelatihan Pertolongan Pertama
17
pada Kecelakaan kerja dan penyakit darurat di
tempat kerja
18 Mampu mengembangkan dan mengimplementasikan
disaster plan yang sesuai dengan tempat kerja
 CONCLUSION
• Occupational health has become more
important in the last years
• Many national health programs now include
workers as their target group
• Recognition of OH professionals, including
Occupational Medicine Specialists by
government and other sectors has increased
in the last years

8/23/2017 OH in INDONESIA AS 40
 RECOMMENDATION
• Effective occupational helath programs need:
– Improved coordination between ministries and
other stakeholders
– Enforcement of existing laws and regulation
– Improved competencies of OH professionals
– Increase participation of the workers community

8/23/2017 OH in INDONESIA AS 41
 Occupational Medicine Services for
ALL

42 8/23/2017 Pelayanan Kedokteran Okupasi - A.S

THANK YOU !
 Performing Arts
Medicine
JOGYA, AUGUST 2017
Sick of passion / sick from
passion
INTRODUCTION TO DANCE AND MUSIC MEDICINE IN
RELATION TO OCCUPATIONAL MEDICINE

LAILANA PURVIS, MD, MSC, OHS, MBA, BA

 Dance and Music Medicine focuses on scientific
research of the healthy functions and disorders,
somatic or psychological,
 which play a role in making music or dancing, as
well as the
 prevention,
 diagnosis and
 treatment of diseases which dancers and
musicians can encounter.
Nederlandse Vereniging voor Dans-
en Muziekgeneeskunde
 Founded in 2005
 Broadens and deepens the interest and knowledge
in the field of medicine and medicine for dancers
and musicians
 Promoting contact between physicians,
psychologists, physiotherapists, medical students
etc. with interest and passion for this form of
medicine
 Providing scientific framework for dance and music
medicine
 the Medical Centre for Dancers and Musicians is
located In the Medical Center Haaglanden
 Unique in Europe; orthopedist, Boni Rietveld, works
fulltime as a consultant for dance and music
medicine
 Various specialists as a consultant, specializing in
specific medical problems in dance and music
 Recently, a psychiatric outpatient and a
neuropsychological clinic has been founded

 Rehabilitation Friesland has a rehabilitation ward

for musicians
 Beatrixoord Groningen also has a clinic for
musicians
Stats

 In the Netherlands: 2500 - 3000 professional

dancers (including teachers and students.)
 About 300,000 amateur dancers (incl. ballroom
en latin dancing)
 Additionally 20000-25000 professional musicians
 70000 popgroups
 1-2 million amateur musicians
In every OH practice: about 40 amateur
dancers and 400-800 amateur musicians
 Always ask about work, sports , hobbys…
 Also if they play an instrument, dance, sing
 Each “instrument” has its own injury repertoire
 Dancers: especially orthopedic injuries: back, hip,
knee, ankle and foot
 Musicians notably problems of the upper extremity:
back and neck, shoulder, elbow, wrist and hand
 Singers: particularly vocal cord problems
 All performing artists have to deal or have had to deal
with stage fright
 Dancing is a professional sport on the square meter;
 a dancer without pain does not exist.
 Making music is top sport on the square centimeter;
 a musician with pain has a potentially big
problem
Arabesque Attitude
Dancers: specific back
problems
 A unilateral painful arabesque is a stress fracture
until the contrary is proved.
 Always refer with this type of complaints.
 Diagnosis: X-ray / technetiumscan
 Treatment is only useful if recent onset (active bone
scan).
 Longer existent: treatment as with lumbago
 NEVER advise to stop dancing
Demi plié
 Result: torque on the knees with a rotatoir
malalignment of the patellofemoral joint and
stress on the medial structures, “screwing your
knees“
 Consequences: patellofemoral symptoms and risk
(lateral) patellar dislocation
 Therapy: Careful turnout technique: lessons !!

 Well treated patellar dislocation is

no reason to stop dancing!
Dancers: ankle problems
 Ankle Injuries: 27% of all injuries
 Consistency with extreme plantar flexion
(dancing a pointe)
 Common problems:
 Dancers Heel (posterior impingement syndrome)
 Dancers Tendinitis
Dancing a pointe
Dancersheel
Musicians
General treatment principles
 In general, conservative principles:
 Therapeutic consultation with explanations and
advice
 Posture and exercise, usually based on
specialized physiotherapy
 Other conservative therapies: injections,
immobilization, splinting, adapted instruments
 Because the motor skills of the hands is very
delicate, and the actual tools of the musician
forms , one is very cautious towards surgical
therapy
Attitude violinplayer
Back and neck pain

 Almost always due to attitude

 Myalgia of the trapezius muscle and thoracic
outlet syndrome:
 Tendency to hyperlordosing of the neck using
reading glasses to look at the lectern, often
accompanied by protraction of the shoulders,
causing the m. pectoralis minor pinching the
brachial plexus.
 Treatment: explanation, physiotherapy and
possibly music spectacles
Shoulder problems

 Impingement of m. supraspinatus
 Prolonged statical posture of the forearm
(violinplayers, flutists)
 Right abduction and left adduction:
 “wringing out” of the rotatorcuff
 Minimal bloodflow(critical zone of rotatorcuff)
 subacromial impingement
Shoulder: treatment

 Wringing out arises particularly with adduction of

the arm:
 Extra attention to strengthening the lateral
rotators to prevent wringing out.
 Scapular stabilization (exercise) to limit forward tilt
of the shoulder
 Sometimes ergonomic instrument adjustment:
extra curvature, extended flaps etc. : custom
made
 Also operative treatment of impingement
syndrome is possible, but is avoided as much as
possible
flutist
Elbow

 Guitar players: pinching of the nerve against the

soundboard

 Complaint: pain on the medial side of the elbow

and paresthesias ulnar side of the hand

 Treatment: night splint to prevent far-flexion; less

flexion of the elbow during play: learning from a
skilled physiotherapist
 Sometimes neurolysis.
m. Flexor carpi ulnaris
Wrist
 Many complaints of the wrist:

 Carpal tunnel syndrome

 Quervain’s Disease (adductor pollicis longus

and extensor pollicis brevis)

 Finkelstein test
Anatomie
The hand

 Triggerfingers and Dupuytren’s Disease

 Malletfinger : carreer threathening

 Polyartrosis DIP-joints: silver ring splint

Silver ring splint
Singers

 Instrument: the larynx

 Most common problem: vocal cord problems
 Often overload due to inadequate technique

 Vocal cords work as harmonica

 Tightened by arytenoids
 Air lets the vocal cords vibrate
 Length of the vocal cord determines the height
 Mouth, oral cavity and skull (soundboard) define
timbre
Anatomy
Vocal cord problems
 Most common: vocal cord nodule or polyp
 Due to overload: bad singing technique, shout
 Complaint: hoarse, quickly lost voice
 Therapy: surgical, then rest 2-3 months and then
build good singing voice use under guidance.
Symphonic Orchestra
Symphonic orchestra
Deafness

 Deafness is a common problem among

musicians
 A variety of preventive measures possible
 Wearing otoplastics is recommended but leads
to difficulties hearing small differences, which are
especially important in classical music
 Violinists have more hearing problems than
trumpet players: they sit in front of the copper
instruments in the orchestra, and always in loud
noise
“the nerves”:
psychological problems

 Stage fright occurs in 70% of stage artists (British

Association for Performing Arts Medicine 1997)
 Orchestra Musicians: 39% psychological problems,
of which stage fright 24.7% (Middlesbrough Town
& Fishbein 1988)
 No more psychiatric disorders than in general
population but more ADHD and addictions (van
Eekeren 1999)
Profession specific stressors
 More soli - more stress
 Hierarchical phenomena (conductor -
concertmaster)
 Adverse playing conditions
 Out of touch with the music
 Poor organization of a music tour
 Still have to prove through continuous auditing
 Uncertainty about finances
 The show must go on, even in illness
Janine Jansen: exploiting
a violin player
Ending / take home
messages
 The main problem with passionate performing
artists is the fact that they are usually much too
late to see a doctor, for fear that his or her
playing, dancing, singing is prohibited.

 Therefore, even minor complaints must be taken

seriously by performers and doctors

 The advice to quit or "take it easy" causes the

patient to no longer visit the practice
Thank you for your attention
 Biannual meeting followed by scientific and artistic
symposium "Art and Healing";
 Active participation in the international journal
"Medical Problems of Performing Artists“
 Participation in international research and
international associations such as IADMS:
International Association for Dance Medicine and
Science ( founded in 1990)
 Annual Symposium on Medical Problems of
Performing Artists
Elbow

 Ulnar neuropathy in the cubital tunnel

 Common in musicians (9%), more often than CTS
 Causes: prolonged far flexion of the elbow
(violinplayers) with simultaneous compression by
the two heads of flexor carpi ulnaris (FCU), which
stabilizes the os pisiforme in the abduction of the
little finger.
 Also with spreading the fifth finger at forceful
touch with pianists, bass players
Anatomy in vivo
Anatomy