Since the onset of reform and opening-up policies, China has risen to become the world’s
second-largest economy. This transformative period has witnessed considerable advancements
in medical services provision, resulting in significant improvements in the overall
healthcare landscape. A noteworthy accomplishment is the creation of the world’s largest
and most comprehensive social security system. Adhering to principles of inclusivity,
multi-tiered coverage, and long-term sustainability, this system guarantees the fulfillment
of basic life necessities. By the end of 2022, over 1 billion individuals were covered
by basic old-age insurance, 238 million by unemployment insurance, 291 million by
work-related injury insurance, and more than 1.3 billion by basic medical insurance
(1). Despite extraordinary progress, noticeable gaps remain in healthcare and support
services. This is especially true for migrant workers suffering from pneumoconiosis,
a condition induced by prolonged exposure to dust in the workplace.
Advancements in the Prevention and Treatment of Pneumoconiosis in China
Current situation
As of the end of 2021, China reported approximately 951,000 pneumoconiosis cases,
constituting a significant portion-90%-of all occupational disease cases. There are
approximately 450,000 active cases of occupational pneumoconiosis, primarily from
coal workers’ pneumoconiosis (CWP) and silicosis (2). Unfortunately, there are scarce
effective pharmaceutical interventions and technologies to halt the progression of
pneumoconiosis, which often coincides with other conditions such as pulmonary tuberculosis
(PTB), chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension
(PAH), lung cancer, and mesothelioma; these comorbidities further degrade patients’
quality of life. Alarmingly, statistical data indicate that approximately 7.5% of
pneumoconiosis patients in China also suffer from PTB (3). Pneumoconiosis remains
the most prevalent and severe occupational disease nationwide.
Efforts and achievements
The Chinese government has shown a consistent commitment toward the prevention and
management of pneumoconiosis. In the 1960s, a robust set of dust prevention measures,
known as the Eight-Figure Policy, was established. This strategy included technological
innovation, wet dust removal, sealing, ventilation, personal protection, administration
systems, health education, and audits, whereby it adopted a comprehensive approach
that resulted in significant outcomes. Later, in the 1980s, the People’s Republic
of China promulgated the Regulations on Prevention and Control of Pneumoconiosis,
which was further bolstered by the introduction of the Law on Prevention and Control
of Occupational Diseases in 2002, coupled with relevant regulations. This series of
legislative measures has formed a strong legislative framework for the prevention
of pneumoconiosis.
A handful of nations worldwide, namely China, the United States, the United Kingdom,
New Zealand, Germany, and Finland, have established robust data collection systems
relating to occupational disease (4). Over the prior decade, remarkable progress has
been made in legislation, standardization systems, regulatory frameworks, prevention
of occupational diseases, and dust control, all of which have been realized through
the collaborative efforts of relevant institutions, departments, and governments at
various levels. An administrative body has been established specifically to address
occupational health hazards, thereby bolstering technical service capabilities and
providing support within the occupational health field. Surveillance of occupational
diseases and harmful agents has been expanded, with comprehensive measures being implemented
to secure occupational health conditions (5). The results of these endeavors are undeniable
— there has been a significant decrease in newly reported occupational diseases in
China, from 26,393 cases in 2013 to 11,108 in 2022, representing a 58% reduction.
The continuing challenges
Pneumoconiosis is universally acknowledged as the most common occupational disease,
representing a substantial public health concern globally. Numerous industries worldwide
are associated with exposure to respirable crystalline silica (RCS) dust, the chief
cause of silicosis. These industries encompass quarrying, mining, mineral processing,
foundry operations, brick and tile production, refractory processing, and construction
actions involving materials such as stone, brick, concrete, and insulation boards
(6). Moreover, the risks posed by dust exposure pervade an array of sectors beyond
conventional industries such as construction and building, extending to evolving sectors.
These include stone cutting, kitchen benchtop fabrication with artificial stone, dental
prosthetic creation, and even stone-washed jeans manufacturing (7).
Once controlled in developed countries, pneumoconiosis among coal miners has emerged
anew in the 21st century, particularly in nations such as the United States and Australia
(8). The rapid urbanization and industrialization process in China has exposed many
secondary industry workers to dust, a leading contributor to pneumoconiosis. The coal
mining workforce in China numbered six million prior to 1995, which has now dwindled
to approximately 2.9 million. The high levels of pneumoconiosis incidence and prevalence
rates among these miners nonetheless remains troubling (9).
The 2020 National Occupational Hazard Survey unveiled startling results regarding
the state of China’s leading industries — mining, manufacturing, and electricity,
gas, and water production and supply. The survey indicates that an estimated 69.3%
of businesses in these sectors are exposed to dust hazards. Moreover, approximately
47.4% of the workforce exposed to work-related hazards are at risk from dust-related
dangers (10). Given the long latency period of pneumoconiosis, which typically spans
10 to 20 years or more, it is plausible to anticipate a significant surge in new pneumoconiosis
cases in upcoming years. It is of equal concern that employment injury insurance covers
less than 30% of migrant workers, who primarily constitute the workforce in dust-exposed
environments. The absence of sufficient insurance coverage amplifies the difficulties
in diagnosing, treating, and providing medical support to those affected by pneumoconiosis.
Therefore, these challenges emerge as crucial present and prospective public health
concerns in China.
Present Features and Challenges
Legal, regulatory, and governance frameworks
Substantial revision is needed in the existing regulations and technical standards
aimed at pneumoconiosis prevention and control. Their outmoded state impedes accommodation
of both individual and private organizations thriving in the present market economy.
This lack of alignment extends to workers involved in labor dispatching, outsourcing,
platform-based engagements, and part-time employments. Furthermore, there is a dearth
of early warning systems and prompt control strategies for managing emerging hazards.
Second, the approach to occupational disease management in numerous small to medium-sized
enterprises confronted with dust-related risks is deficient. These workplaces often
exhibit dust concentrations that fail to align with national health standards, lack
essential dust-control facilities, and display inconsistent implementation of compulsory
occupational health surveillance. This raises the implication that official reports
may underrepresent the true extent of occupational diseases in China.
Third, the efficacy of occupational health supervision, particularly at the county
level, is impeded by a lack of dedicated professionals with expertise in occupational
health. This personnel deficit hampers the capacity of such supervisory entities to
appropriately execute their regulatory functions.
Diagnosis and management of diseases
Current diagnostic methods for occupational pneumoconiosis lack cohesion, and the
onus of managing labor relations and work-related injury compensation does not fall
on the health department. This fragmented system hampers medical and health institutions
from efficiently collecting employment histories and occupational disease data. Furthermore,
there is anoticeable deficit of scientific criteria for diagnosing pneumoconiosis
in the clinical field. Presently, the process of diagnosing occupational pneumoconiosis
heavily relies on comparing patients’ chest X-ray images to a standardized reference
film. However, this comparison method fails to optimally assist with early diagnoses,
disease assessments, and prognosis guidance. Furthermore, a common issue is that patients
often find this diagnostic process difficult to comprehend, which further complicates
the situation.
Technical assistance and scientific proficiency
The dearth of robust, thorough research on the hazards associated with dust has hindered
significant progress in fundamental theoretical explorations. This scarcity of dedicated
inquiry into such critical scientific issues impairs the progression of innovative
technologies. Additionally, the unavailability of extensive and transferable pneumoconiosis
reporting systems makes it difficult to ascertain reliable morbidity and mortality
rates. This uncertainty prevents both researchers and the general population from
acquiring a comprehensive understanding of pneumoconiosis, thereby obstructing the
development of region-specific and departmental policy measures for preventing and
managing this disease. A lack of cross-disciplinary expertise for preventing and treating
of pneumoconiosis has led to inferior professional and technical standards for diagnosing
and treating occupational health ailments compared with non-occupational respiratory
diseases. The sporadic accessibility of national clinical resources and pertinent
biometric information related to pneumoconiosis hampers the feasibility of conducting
in-depth research in this area.
Approaches to the management of pneumoconiosis
A holistic approach is deemed most effective for the management of pneumoconiosis,
incorporating elements such as smoking cessation, oxygen therapy, rehabilitation,
pharmaceutical interventions, and the consideration of innovative lung transplantation
techniques for end-stage disease. The primary goals are to retard the degradation
of lung function, deter disease progression, enhance patients’ quality of life, prevent
complications, and lower mortality rates. However, a substantial deficit remains in
the inclusive theoretical and experiential research in this domain. An array of patients
grapple with the long-term financial burden stemming from healthcare costs. Community-based
medical insurance frequently falls short, leaving patients with restricted resources
for self-management. This consequently results in a significant number of patients
deficient in efficient management of complications, fostering rapid disease progression,
and resulting in escalated disability and mortality rates.
Industrial injury insurance as a component of social security
The existing industrial injury insurance system grapples with numerous challenges
in its designand implementation. These encompass inadequate coverage for migrant workers,
limited access for most independent workers, and problems encountered when trying
to access industrial injury insurance benefits following a change of job. Given their
high levels ofmobility and unclear labor relationships, migrant workers often have
difficulty documenting their history of occupational dust exposure. Consequently,
establishing a causal link between their illnesses and occupational factors can be
problematic. Individuals with pneumoconiosis are inadequately protected, facing hurdles
such as limited re-employmentopportunities, financial strains due to their health
conditions, and insufficient social support.
Recommendations and Future Directions
The endorsement of the Healthy China Initiative at the 19th National Congress of the
Communist Party of China reflects a commitment to public health, population wellbeing,
and the establishment of a healthy nation. To realize the goals set forth in the Healthy
China 2030 Planning Outline, the General Office of the State Council advanced the
Opinions on Implementing the Healthy China Action. Within this framework, the Occupational
Health Protection Action was conceived to enhance prevention and management of occupational
diseases, including pneumoconiosis. Adhering to the objectives outlined in the Action
Plan for the Prevention and Control of Pneumoconiosis, it is anticipated that by 2022
and 2030, there will be a significant and continuing decline in the ratio of new pneumoconiosis
cases reported from workers with less than five years of dust exposure to the total
number of annual reports.
The evidence from our analysis suggests a significant influence of several social
and risk factors on the rising prevalence of pneumoconiosis among coal miners in China.
Factors such as societal coal demands, industrial strategies, coal industry workforce
size, employment structures, coal productivity, enterprise characteristics, scale
of operations, mining technologies, dust control strategies, occupational health evaluations,
pneumoconiosis diagnosis and reporting systems, occupational health management and
regulation, and social security provisions all contribute to the issue. Consequently,
it underscores the need for a comprehensive, multidisciplinary initiative across scientific,
engineering, medical, managerial, societal, political, economic, and legal sectors
to effectively address and ultimately eradicate pneumoconiosis.
In accordance with the “Healthy China” initiative, there is a pressing need for proactive
strategies. These should comprise legislative and regulatory improvements, progress
in the categorization and diagnosis of pneumoconiosis, fortification of management
procedures, bolstering of technical support and scientific capabilities, along with
the broadening of industrial injury insurance and social security provisions.
Laws, regulations, and governance systems
The mandates stipulated in the Law of the People’s Republic of China on the Prevention
and Control of Occupational Diseases and the Regulations on Work-Related Injury Insurance,
along with its associated laws and standards, necessitate a thorough and systematic
examination. With regards to both core health promotion guidelines and the distinct
attributes of the primary stage of socialism, the establishment of a cost-effective
occupational health service framework is recommended. Moreover, initiating supplementary
liability insurance for employers at a heightened risk of pneumoconiosis could be
considered beneficial. Appropriate interventions such as these could significantly
improve the monitoring and control of dust-related hazards.
In the field of occupational health management, it is crucial to develop and apply
novel strategies. An approach under consideration involves the fusion of on-site supervision,
law enforcement, as well as hazard detection and assessment, piloted in certain industries
or regions. This tactic intends to improve management of supervision information through
network-based systems. Additionally, it is important to investigate the potential
for developing a governance structure for registered occupational hygienists. An essential
focus should be the cultivation of a collaborative linkage mechanism that includes
grassroots governments, fostering cross-sectoral cooperation. This mechanism would
necessitate the formulation of a tripartite coordination framework that involves workers,
employers, and governmental entities. Furthermore, a paramount objective is to devise
a rating and blacklisting system for occupational disease prevention and control.
This system would establish and enforce accountability and deterrence, thereby facilitating
rigorous actions against illegal activities.
Diagnosis and management strategies
A proactive stance must be taken towards establishing a solid framework for the clinical
identification and determination of pneumoconiosis. In light of the specific dynamics
related to clinical identification and occupational attribution in patients suffering
from pneumoconiosis, it is deemed necessary to reform the system for the diagnosis
of occupational pneumoconiosis in two critical ways, drawing upon practices from developed
countries dealing with occupational diseases. The revised system should fundamentally
consist of two parts: the clinical identification of pneumoconiosis that is linked
with the recognition of occupational exposure and causal connections; and second,
the onus should fall on regulatory entities to confirm essential information required
for the diagnosis of occupational diseases.
Additionally, the proposal recommends integrating pneumoconiosis into the basic social
medical insurance framework. This action would facilitate parity between routine and
occupational injury medical insurance. Patients diagnosed with occupational pneumoconiosis
would hence have access to occupational injury medical insurance coverage. We encourage
a more extensive application of existing policies — including basic medical insurance,
critical illness insurance, medical aid, public welfare assistance funds, and life
assistance programs — for those individuals not protected by occupational injury insurance
or those whose employers have ceased operations.
Technical assistance and scientific proficiency
The establishment of an integrated medical innovation system connecting scientific
research, prevention, diagnosis, and management of pneumoconiosis is of critical importance.
This warrants the strengthening of fundamental research facilities and platforms in
medical institutions, in addition to enhancing the effective allocation of resources
for public health and medical initiatives. A proposal for a nationwide, open pneumoconiosis
information reporting system, bolstered by an expansive national database encompassing
clinical resources and biometric information associated with pneumoconiosis cases,
is tabled. It is worth underscoring the significance of enhancing the education and
training structure, with the aim of integrating public health education and clinical
medical perspectives. This effort calls for the reinforcement of educational and training
institutions responsible for nurturing the requisite skills and competencies for pneumoconiosis
prevention and management. Moreover, increasing investments in scientific research
centered on dust prevention and control as well as the diagnosis and management of
pneumoconiosis is advocated to widen and deepen our comprehension in these fields.
A comprehensive approach to healthcare management in patient care
The inclusion of pneumoconiosis prevention and management within the foundational
public health service system is advocated. Such a process necessitates an escalation
in funding, reinforcement of the closed-loop dynamic management model, and a broadening
of the multi-tier rehabilitation system. This expansive network incorporates representatives
at the state, provincial, city, county, and town or community level, in addition to
families and individuals. The proposition also extends to the establishment of a national
occupational disease medical rehabilitation guidance center to augment the proficiency
of primary medical rehabilitation.
Patients with pneumoconiosis should receive targeted treatment, medical interventions,
and comprehensive health management based on their individual risk assessment. With
the growth of China’s economy, priority should be given to initiating occupational
health exams and follow-up care for dust-exposed workers who have left their positions.
This initiative should first be trialed in more developed provincial-level administrative
divisions before gradually being implemented nationwide. The ultimate goal is to guarantee
comprehensive, lifelong health management for all workers exposed to dust.
The call for a robust medical innovation system encompassing scientific research,
prevention, diagnosis, and treatment of pneumoconiosis is both immediate and paramount.
To achieve this, a significant strengthening of primary research facilities and platforms
in medical institutions is necessary, in tandem with an increase in the efficiency
of public health and medical resource allocation. We strongly advocate the inauguration
of a nationwide pneumoconiosis information reporting system, coupled with developing
a comprehensive database for national pneumoconiosis clinical resources and biometric
information. There is also a need to enhance our education and training framework.
This will require integrating public health education and clinical medicine to ensure
a holistic learning experience. Subsequently, we propose the expansion and improvement
of education and training centers dedicated to fostering expertise in pneumoconiosis
prevention and management. Furthermore, we suggest prioritizing increased investments
in scientific research pertaining to dust prevention and control, along with research
into the diagnosis and management of pneumoconiosis. We anticipate that this strategy
will significantly advance our understanding and expertise in these crucial fields.
Industrial injury insurance in relation to social security
The initial stage in this process necessitates a comprehensive review and enhancement
of laws and regulations pertaining to industrial injury insurance. The focus will
transition from a mere compensation approach, moving toward more active prevention
procedures. This methodology is designed to strengthen health advocacy and secure
employment for workers endangered by dust-related hazards. The program seeks to encompass
a varied workforce, which includes migrant labor(s), dispatched workers, outsourced
personnel, platform-based and part-time employees, as well as participants in the
gig economy. Considering the gradual and hidden progression of pneumoconiosis, it
is vital to formulate a sturdy, long-term protection strategy for industrial injuries.
This system should safeguard the health and welfare rights of those workers affected
by pneumoconiosis, even after their departure from the workforce or retirement. Additionally,
the suggestion to incorporate pneumoconiosis into the social basic medical insurance
directory has been proposed, thereby allowing the parallel existence of medical insurance
and industrial injury insurance.
Enhancing the medical security system is a vital progression which can be achieved
through the execution of specific policies aimed at civil aid, and solidifying the
creation of a linkage mechanism incorporating societal resources. This cooperative
endeavor ensures a proactive role in bolstering medical security.
Advocacy is encouraged at the state level for the establishment of distinct national
and local funding streams targeting pneumoconiosis. This includes the implementation
of a specialized security framework with provisions for patients suffering from occupational
diseases. These provisions are particularly aimed at patients whose employers have
gone out of business or whose labor relations are unverifiable, ensuring they receive
medical assistance and livelihood protection.
Conflicts of interest
No conflicts of interest.