Section on Work and Health

THE NEW CORPORATE HEALTH ETHIC: LIFESTYLE AND THE SOCIAL CONTROL OF WORK Peter Conrad and Diana Chapman Walsh A corporate health ethic, forged in U.S. industry in the 20th century, clearly demarcated boundaries between private and workplace health concerns. This article advances evidence that the boundary is blurring, and argues that trends in workplace initiatives, including employee assistance, wellness programs, and drug screening, are giving shape to a new corporate health ethic. The new ethic emphasizes workers’ lifestyles on and off the job, en endering a shift in corporate jurisdiction over employee health and behavior. l ! a nomic arguments such as “health care cost containment” are commonly offered as explanations for these new health initiatives. But the authors see the new ethic as a deeper response to a changing corporate environment and, more fundamentally, as emblematic of changes in the social control of work and productivity. They argue that the new health ethic may be a harbinger of new forms of social control in the workplace.

Observers of work organizations have long been interested in the reciprocal relationship between work and health. Social scientists have studied reform movements and workers’ struggles to expose and reduce job hazards (1-3), but have focused less direct attention on the other side of the work-health nexus: how employers factor health considerations into workforce management and productivity control. From the 1920son, the gradual growth of industrial health programs in large corporations institutionalized a corporate medical presence in the workplace and established occupational medicine as a recognized specialty (4). Programs were developed to screen for disease and to identify and treat alcohol-abusing employees. Insurance coverage for medical care was attached to the employment relationship. As these employee health programs took shape, they developed a largely implicit but clearly circumscribed jurisdiction. Occupational health programs would address only problems associated directly with work-problems that either emanated from job exposures or affected work performance. A crucial distinction was thus made between health on and off the job, and a line was clearly drawn between work and private life. This article advances evidence that the distinction has begun to erode, blurring jurisdictional boundaries between work and private life. In particular, we examine three evolving health initiatives in the workplace-“employee assistance,” worksite

Diana Chapman Walsh h partially funded as a Kellogg National Fellow and through grants from the Commonwealth Fund, the Pew Memorial Trust, and the National Institute on Alcohol Abuse and Alcoholism.

International Journal of Health Services, Volume 22,Number 1, Pages 8S111, 1992 0 1992, Baywood Publishing Co., Inc.

89

doi: 10.2190/FGYX-6EBJ-70QT-0T4E http://baywood.com

90 I Conrad and Walsh “wellness,” and screening for drugs-and draw out their new emphasis on workers’ lifestyles on the job and off. Together, these trends are creating what we call a “new corporate health ethic,” which we locate in the changing needs and structures of U.S. business firms. To analyze the new health ethic, we first distinguish it from traditional corporate attitudes toward the health of workers. We then describe the three emergent worksite health initiatives that illustrate how the new corporate health ethic has been unfolding. Next we examine two partial explanations for its emergence. Although the new health initiatives are most often placed in the context of “health care cost containment,” we find this economic argument an inadequate explanatory framework for the expansion of corporate health consciousness. Our final section develops an alternative sociological perspective on the new corporate health ethic as a more fundamental response to a changing corporate environment and perhaps a harbinger of new forms of social control in the workplace. TRADITIONAL EMPLOYER CONCERNS AND THE OLD CORPORATE HEALTH ETHIC In the first third of the 20th century, several overlapping and loosely related developments in U.S. industry’s concerns about workers’ health laid the groundwork for what might be called the old corporate health ethic. These changes included the rise and demise of U.S. welfare capitalism, the development of state workers’ compensation systems, the emergence of “industrial” (subsequently “occupational”) medicine, and a decade or so later, the advent of corporate-sponsored health insurance. Together, these developments forged a corporate health ethic that granted the existence of a clear boundary separating private and workplace health concerns. Industrial medicine originally arose around the turn of the century, when employers running railroading, lumbering, and mining operations in remote locations began to provide basic medical services for their employees, in response to the accidents and emergencies that were occurring with increasing regularity. Involuntary payroll deductions were sometimes used to finance such services and to entice physicians to settle in isolated areas by assuring them a steady income (5). These early medical programs were among several instruments of welfare capitalism, a system in which some companies owned and operated for their employees many elements of the basic community infrastructure: stores, a variety of service delivery systems, housing, sometimes whole towns (6). Indirectly, employers assumed tremendous power over workers’ lives, and organized labor began to chafe against this paternalism and its implication that workers lacked the good sense to invest in their own health and welfare (7). During the 193Os, New Deal legislation recognized U.S.labor relations as an essentially adversarial system, with companies pressing for more control over the terms and conditions of work and unions standing firm in their resistance to encroachments onto the laborer’s turf, including his or her private life (8,9). The evolution of workers’ compensation systems was part of this struggle to locate responsibility for health and safety on the job. Beginning around 1900, the explosion of job injuries and deaths accompanyingthe spread of industrial growth was arousing some public attention to the plight of workers injured on their jobs and the survivors of those killed (10, 11). Voluntary relief and benefit societies were established to compensate

New Corporate Health Ethic / 91 victims or their survivors. But recompense from employers was rare and wholly inadequate. Political pressures eventuated in the passage, state-by-state, of workers’ compensation laws (11-14). By 1920 all but six states had enacted statutes limiting the employer’s common law defenses against workers’ claims for compensation of injuries sustained at work. This functioned to rationalize some worker protection by making it a cost of doing business. The focus of the laws was limited, however, to injuries directly attributable to an event on the job. Even as expansion of the laws over the years encompassed longer-latency and less easily documented occupational diseases, the realm of employer responsibility remained limited to health problems for which “work-relatedness” could be demonstrated (1, 12, 15, 16). Explicit boundaries remained around the workplace as far as the employer’s responsibility was concerned. In the context of the new compensation systems the specialty of Occupational medicine began to take form (4). Companies established in-house medical programs to help prevent injuries and illnesses on the job and to mitigate potential losses as the new compensation systems were erected. By 1916, according to one estimate, physicians were working on site at over 170 industrial establishments, together employing over a million workers (17). The number of such programs increased further after World War I. Staffed by physicians and nurses, the function of these departments was to assess the fitness of workers to perform their jobs, conduct periodic examinations, and stand by to treat illnesses or injuries that might arise at work. Company medical practitioners always drew a sharp distinction between health problems that were job-related and those independent of work. This distinction was codified in official policy of the American Medical Association-intent (as a German corporate medical director phrased it) on “keeping butter for the private practitioner’s bread” (4). But it was also adhered to by occupational physicians themselves, reluctant to challenge the powerful organized medical profession, and satisfied that the unique work of occupational medicine was challenge enough. As late as the 1970s, corporate medical leaders were still acutely conscious of issues of medical turf. A 1971 survey by the Conference Board noted reluctance on the part of corporate executives to increase company involvement in nonoccupational health care, and cited, as the primary reason, “deference to what many management executives, and many occupational physicians as well, regard as the economic or marketing rights of private physicians” (18). At a 1977 national conference, the corporate medical director of New York Telephone Company articulated the occupational physician’s frustration concerning the constrictions on the terrain she or he could legitimately claim (4, p. 60): Until very recently, the fundamental concept that there is a vast and absolute distinction between things which are related to job and things which are not related to job had pervaded our thought and action. With almost religious fervor, occupational medicine tried to stay out of those things which were not related to jobs. The distinction between occupational and nonoccupational was the daily grist of occupational medicine, often winding up in litigation to determine whether a condition was caused by job or was not and therefore, in the mind of the occupational physician, whether it was in his legitimate province or that of those other guys out there in the community. It’s going to take us a long time to get over that because it is deeply ingrained.

. ..

92 I Conrad and Walsh Meanwhile, employees’ financial access to general medical care was becoming attached to the employment relationship, as health insurance took form. A crucial principle of health insurance was that employees would remain entirely free to choose their own providers of care. This, combined with the role of insurance carriers as third-party intermediatesprocessing and paying claims, positioned the insurers between corporations and workers and greatly diluted the employer’s involvement in, knowledge of, and responsibility for the care rendered.’ Again, the net effect was to keep corporations out of the domain of workers’ lives off the job, even though they were financing personal health care through the benefit plan. Underlying these diverse health concerns as they evolved up to the decade of the 1970s was a clear corporate ethic governing employee health. In short, the traditional health ethic was explicitly confined to the workplace; it included only health concerns specific to the job and discouraged the employer from intruding into that segment of a worker’s life for which he or she had not paid. EMERGENT CORPORATEHEALTH CONCERNS In the past 15 years corporations have shown new or intensified interest in the health of their employees, especially (although not exclusively) in the programs related to counseling or “employee assistance,” wellness, and screening for drugs. While each of these initiatives has a particular focus that is manifest in specific programs, all three represent an expansion of corporate attention to employee lifestyle and health. There is some overlap among the three types of corporate health programs. Screening, for example, is a technology occasionally used by both employee assistance and wellness programs, and the latter two types of programs begin to resemble one another when the focus is primary prevention of problems such as stress or substance abuse. Nevertheless, the three are distinct enough to be discussed separately, each illustrating in a different way the new and broader ethic that attracts employers’ attention to their workers’ lifestyles on the job and off. The WideningNet of Employee Assistance

One major area of expanding corporate jurisdiction and concern is in the growth and elaboration of programs to deal with employees’ alcohol abuse and other personal or emotional problems. Contemporary “employee assistance programs (EAPs)” involve policies and procedures for identifying and responding to personal or emotional problems that may be interfering, directly or indirectly, with employees’ ability to function on the job (19). The targets of such programs have become so broad and diffuse that many make themselves available to help employees and their families cope with virtually any stress of modern life. They cushion the impact of financial or legal

’

It is interesting to note that contemporary enthusiasm for “managed care,” “utilization management,” “benefit plan redesign,” and other intensified efforts to channel and constrain employees’ decisions about where and when to seek medical treatment has moved corporations also into this domain that was once reserved for the worker’s autonomy. But because only indirectly related to lifestyle, this trend is less central to the argument we advance here.

New Corporate Health Ethic / 93 setbacks, secure treatment for a problem with alcohol or drugs, find counseling for a troubled adolescent or a disintegrating marriage, identify resources to deal with the care of small children or infirm elderly parents, teach techniques to master stress and to manage conflict, organize literacy training efforts, and otherwise intervene to shore up employees’ vanishing systems of social support (20). Employee assistance programs originated in single-focus efforts to confront working alcoholics and persuade them to seek help through the fellowship of Alcoholics Anonymous. The first official occupational alcoholism program, established in the 193Os, combined the businessperson~sawareness of the obvious costs and disruptions of alcohol abuse with the humanitarian impulse being advanced by proponents of the then-novel idea that alcoholism was a disease whose victims could successfully be treated. In part owing to the energies of these activists, the number of worksite programs grew, according to one estimate, from four to six in the 1940s to at least 50 a decade later (21). Through this evolution, a central premise that became increasingly explicit was that employers had a legitimate right to concern themselves with the worker’s personal affairs (such as drinking habits) when and onZy when they affected his or her performance on the job (19). Much attention was accordingly paid to defining the separate roles of front-line supervisors and administrators of EAPs. The supervisors’ role was confined to what they were viewed as capable of doing best: overseeing and documenting job performance, and referring “troubled employees” to the expert in substance abuse, whose responsibility was to make the diagnosis and referral for whatever ongoing care seemed warranted. Such a division of labor was seen as the best way to dispatch personal problems efficiently and effectively. It also cemented the ideological framework for EAPs: they would address personal problems that employees brought to work, problems that made them less than fully satisfactory employees. If characteristics of the job sapped workers’ performance in the workplace (or, for that matter, at home), these work-design issues remained outside the scope of the EAP (22). The dual strategy that left supervision in the hands of supervisors and moved helping to the jurisdiction of a specialized helper was viewed as not only efficient, but also protective against excessive intrusion into the worker’s life. Confidentiality, it was asserted, could better be preserved if the helping function were separate from routine supervision, and performance evaluation could be conducted dispassionately and without prejudice. The legitimacy of the program seemed secure, so long as it rested on the employer’s right to enforce a standard of job performance. In the early 1970s, however, the distinction between work and private life began to crumble. Advocates of alcohol intervention in the workplace were discouraged that they were reaching a small segment (perhaps one in ten) of workers presumed “at risk,” based on crude estimates of the extent of alcohol problems in the general population. They assumed that potential clients were being kept away from occupational programs by the stigma attached to alcoholism, saw the general cultural shift after the 1960s toward easier acceptance of all forms of psychotherapy, and reasoned that workplace programs with a broader mission than just substance abuse might garner more self-referrals by employees (23, 24). They argued that so-called “broad-brush W s , ” offering a wide range of services to voluntary clients, could identify social adjustment problems of various kinds, which might be masking an alcohol or drug

94 1 ConradandWalsh

problem that the employee would continue to deny unless coaxed in to discuss problems of his or her own choosing. A few published studies lent limited support to this case, which nevertheless seemed more firmly grounded politically and ideologically than empirically (23, p. 148). The redefinition occurred at a time when the case for more encompassing occupational mental health programs (offering social services across a wide spectrum) found reinforcement in a number of social trends, together seeming to demonstrate that alcohol abuse was only one class of personal problem that could affect performance on the job. The drug culture that had its roots in the 1960s led most industrial alcoholism programs to expand their purview to “substance abuse.” Fundamental changes also took place in the demographic composition of the labor force. Great Society legislation in the 1960s pressured companies to hue the hard-core unemployed, and through the 197Os, women joined the labor force in unprecedented numbers, bringing different patterns of helpseeking and different needs for social support both on the job and back at home where they were now spending less time. The family intruded itself into the workplace in unexpected ways (in reluctance to be transferred if it meant uprooting a spouse’s career, and in demands for pregnancy and parental leave and child care benefits). Increasingly, the health and mental health of workers and their families were becoming relevant to workforce management generally. Also, many professional mental health workers tried to move into the workplace in the 1970s, as the government cut back its funding for community mental health programs. The major professional organization representing EAP workers, founded in 1971, grew from 50 or so members that year to 425 in 1974 and 4,500 in 1986 (25), and most of the major helping professions established subspecialties focusing on problems at work. Growth in the numbers of EAF’s was charted by the National Institute on Alcohol Abuse and Alcoholism: by 1973 the 50 programs identified at the end of the 1950s had expanded tenfold, and the growth accelerated through the 1970s, to 2,400 in 1977, and 4,400 in 1980 (21). Although current claims about the prevalence of EAF’s are clouded by definitional ambiguities, one knowledgeable investigatorstates that at least 10,OOO to 12,000 such programs now exist in places of work in the United States (26, p. 137). Other estimates are more restrictive in their definitions, yielding estimates of 1,OOO or fewer such programs overall (27-30), but none leaves room to doubt that there has been an explosion in employee assistance programming during the past decade; only its magnitude is open to debate. More significant than the growth in sheer numbers of programs, however, was the expansion in their purview. The old “job performance” rationale for the employer’s concern had been stretched beyond recognition. Residual lip service was still paid to the J X P justification that employees with troubles at home would miss more work or perform less well. But the close connection between performance and the company’s intervention had been broken by the new emphasis on self-referral into EAPs. Employees who voluntarily sought the assistance of an EAP for help with personal or family problems could not be singled out for unacceptable job performance. The old link between alcohol or drug abuse and tardiness, absenteeism, accidents, and shoddy workmanship had been generalized into a diffuse concern on the part of corporate employers with ways in which their employees’ personal lives might eventually compromise productivity and performance. Walter B. Wriston, as chairman of Citicorp,

New Corporate Health Ethic / 95 articulated this broader view in opening remarks at a 1978 conference on “Mental Wellness Programs for Employees” (20, viii-ix): I would like to share with you the thoughts of one pragmatic banker who is aware that mental health is not only a human problem but, like most human problems, also a business problem.. . .When a manager sees absenteeism rising, or coronary events increasing, he or she knows that it’s not only a human problem but a business challenge. Setting up mental health services to remedy these human problems and restore these employees to full productivity is a rational and legitimate business decision. The more sensitive such programs are to early detection, the better-for the employee, the company and the whole society.

Worksite “Wellness ” Programs

Another avenue from corporate to private life has been through a more recent innovation, known as “worksite wellness programs.” Wellness programs consist of health education, screening, and/or intervention designed to change employees’ behavior in a healthward direction by reducing known health risks, especially those felt to be within employees’ own control. Programs range from single interventions to a whole menu of alternatives and in some cases include well-integrated long-term strategies (31), but even the single intervention programs reflect some of the issues addressed in this article. Wellness programs may include hypertension screening and referral, aerobic exercise and physical fitness instruction, nutrition education and weight control, stress management, smoking cessation, instruction in how to avoid and/or live with back injury, cancer risk screening and reduction, self-care and health information. Many programs begin with some type of “health risk appraisal” to quantify employees’ health risks and inspire them to undertake a regimen to break their risky habits and presumably improve their health. The rapid growth of health promotion or wellness programs occurred in the 1980s (32, 33). A few “pioneer” corporate health promotion programs began in the 1970s (34), but their wide diffusion is a phenomenon of the current decade. Although the number of corporations with programs is unknown, owing largely to definitions that are vague or unspecified, studies suggest that between 21 and 37 percent of all companies have some type of wellness program. The actual prevalence may be higher still; a recent survey of Fortune 500 companies (35) and the government-sponsored National Survey of Worksite Health Promotion Activities (29) both found that 66 percent sponsored at least one kind of health-promoting activity. While considerably fewer have comprehensive programs, there is consistent evidence that both the number and scope of wellness programs are increasing. Innovative and relatively rare less than a decade ago, company-sponsored health promotion initiatives are now commonplace? The key strategy of worksite wellness is to identify employees’ risk factors and develop interventions to reduce overall health risk. For example, for risk factors such as Companies such as Johnson & Johnson, Control Data, AT&T, Tennaco, General Motors, CIGNA, Apple Computer, Coca-Cola, American Express, Pillsbury, Coors, Kimberly-Clark, and Dupont, among many others, have substantial and high-visibility programs to promote their employees’ health.

96 I Conradand Walsh

smoking or elevated blood cholesterol, the wellness program will provide a smoking cessation class or prescribe a dietary change. Although participation in the programs is voluntary, incentives (from T-shirts to cash) are often provided to encourage employees to adopt and maintain the recommended behavioral change (36). A second strategy, less clearly stated, (34, 37, 38) is to use “fitness” as the enticement for participation (39). In virtually all of the comprehensive programs we have visited or examined, fitness activities-aerobics, running, jogging, exercising with special equipment, and the likeare by some distance the most popular and frequently utilized of the program’s offerings. While EAF% are generally directed at employees experiencing problems, wellness programs usually reach out to all employees at a worksite, although some seek especially to target high-risk employees (e.g., those who smoke or are obese). The manifest goal is to change participants’ health-compromising lifestyles and behaviors, irrespective of whether they occur at home or on the job. The level of participation in wellness programs is impossible to estimate, since companies collect andlor report insufficient information on their programs’ penetration and on what level or type of involvement they count as “participation.” Very rough estimates of participation rates range from 20 to 40 percent for on-site programs and 10 to 20 percent for programs financed by corporations but held off their premises (28). Programs tend selectively to attract employees in white-collar jobs, who are younger, somewhat healthier, and already pursuing fitness on their own (40,41). Wellness programs have become a central feature of the corporate cultures of many corporations. While most companies have modest facilities, a few have invested millions of dollars in centralized, sumptuously equipped, and professionally staffed health and fitness centers. Some other companies object to major investments in central facilities and instead subsidize employees’ memberships in fitness clubs and organizations in their communities or contract with voluntary or proprietary health organizations to bring modest programs on site. Advocates of wellness programs usually state their goals in broadly utilitarian terms. The published claims of one company’s wellness staff are fairly typical: “Corporate health promotion programs can substantially reduce health-care costs, employee disability and turnover, as well as premature deaths. . . . In addition, worksite health promotion programs can increase employee productivity by improving satisfaction, morale, mental alertness, and interpersonal relations with workers” (42). While the most commonly cited incentive to corporations for initiating wellness programs is their avowed potential of containing health benefits costs by producing healthier workers who require less medical care, issues such as morale, absenteeism, company loyalty, and productivity may be equally or more important (31, 43). The evidence to support the thesis that wellness programs reduce health care costs is quite thin, although certain program components may be “cost-effective,” in that they more than return the rather modest investments required to support them. Cost savings in any larger framework have not been persuasively documented (44-46). One company’s researchers found in a cross-sectional study that wellness program participants were in general higher performers, granted that selection bias rather than the program probably explained most of the performance increment, and suggested that other companies would nevertheless be well served by programs that appeal especially to the kinds of high-achievers that all employers want to attract and retain (47).

New Corporate Health Ethic / 97 Drug Screening Initiatives

If employee assistance and wellness programs are a mechanism for managing the lifestyles of employees on the payroll, drug screening serves the complementary function of ascertaining who is a desirable employee, one whose lifestyle is acceptable. Screening technologies also enable employers to detect on the job what workers are doing in their leisure time. Testing for traces of drugs in urine samples from employees and prospective employees began in earnest in 1981 when the U.S. Department of Defense instituted screening programs in the uniformed services. By 1988 the trend was well established in private industry, where a third to a half of Fortune 500 companies were reported to have adopted drug-testing policies of various kinds. Some such policies apply only to applicants for new jobs. Others extend to employees whose use of drugs could endanger themselves or others and/or to employees whose behavior betrays evidence of possible drug impairment. A very few are implemented across the workforce in unannounced tests of employees selected at random. Drug testing has occasioned heated controversy and much public attention in the mass media, in at least seven state legislatures, and in numerous court cases. The constitutionality of government-mandated testing of railroad workers was argued in November 1988 before the U.S.Supreme Court. A variety of disparate factors have converged to stimulate the new corporate interest in drug screening. The federal government has been a major instigator, reinforced by extensive media coverage of the “drug crisis.” On September 15, 1986, President Reagan issued an executive order to all federal agencies to introduce programs to achieve a “drug-free” workplace, using strategies that might include compulsory testing of all new job applicants and/or testing of current employees under reasonable suspicion of abuse. This was part of the administration’s “war on drugs,” which also included, from the President’s Commission on Organized Crime, a recommendation that all private U.S. employers screen their employees for drug use in the hope that this would reduce the national demand for drugs, since efforts to interdict supplies at the borders were meeting with little success (48). The most highly publicized reports of employee drug screening have involved professional athletes, police and fiiefighters, and transportation industry personnel (e.g., airline and railroad workers). Although the actual extent of employee drug screening is unknown, evidence points to a significant increase of this practice throughout corporate America? The two-pronged rationale for drug screening is that companies are concerned about the potential costs of drug abuse, especially its effect on productivity, and they also have an obligation to protect employees from the hazards of drugs. The U.S. Chamber of Commerce estimates that drug and alcohol abuse among workers costs employers $60

One report suggested that in 1988 up to half of the top 500 US. companies were performing some kind of drug testing of prospective or current employees, a striking increase from only 3 percent just four years earlier (49). A 1987 survey by the American Management Association estimated that 34 percent of Fortune loo0 companies had drug-testing policies, an increase. of 13 percent in only one year. A 1987 Gallup poll reported that 69 percent of adults agreed with the position or strongly agreed that there should be mandatory drug testing in the workplace, up from 47 percent the previous year (50).

98 I Conradand Walsh

billion a year in lost productivity, accidents, higher medical claims, increased absenteeism, and employee theft (51). Many controversies embedded in workplace drug screening are still being adjudicated. The constitutional issues of privacy, unreasonable search and seizure (of urine samples), and “probable cause” are as yet not fully settled (52). Although the technology of screening has improved in recent years, the problem of false-positive results continues (53, p. lo), and a survey of technical experts, testing laboratories, and arbitrators “reported wide differences in the legal defensability [sic] of methods rated” (54). Laboratory practice (and thus quality) in the $1 billion urine-testing industry varies widely among vendors of service, on whom no minimum standards are imposed. The error rate can run as high as 40 percent according to one estimate (55). Drug-testing programs may also inadvertently single out employees who are taking properly prescribed drugs for medical problems (e.g., epilepsy) and thus invade their privacy (56). The possibility is also raised that screening for drugs and/or alcohol will be a wedge that will eventuate in a wide range of screening programs in the workplace. Examples are possible programs to screen for HIV infection and programs to harness expanding genetic-engineeringtechnologies in the service of screening for hypersusceptibility to cancer, alcoholism, and various other high-cost illnesses, even perhaps congenital d e f ~ c t s . ~ The most telling criticism of drug screening, however, is central to our thesis here. Civil libertarians and other critics of screening have made a strong case that such programs measure employees’ lifestyles but not the adequacy of their job performance. Drug metabolites can still be found in urine days and even weeks after ingestion of the drug. Tests such as the EMIT (enzyme multiplied immunoassay technique), a urine test for screening for marijuana use, can detect “casual use within the last 14 days and chronic usage for much longer periods following discontinuance of use” (59, p. 71). Cocaine residues can be detected three to four days or more after use, depending on the test used. This means an employee can use marijuana or cocaine on a weekend, with no measurable impairment of functioning at work in subsequent days, and yet can test positively on an employer’s drug screen. Thus the employer is (implicitly) monitoring the individual’s personal behavior, not performance on the job. Screening for drug abuse offers “the possibility of knowledge not only about an individual’s health, but also about such things as his or her sexual, drug and alcohol history” (53, p. 7). Drug screening functions as a medical or quasi-medical tool to find a marker for aspects of an employee’s private life. Neither the intoxication effect nor even the frequency or amount of drug use is being measured, merely the evidence of any use over a longer period of time than can be linked to use on the job. The screening procedure seeks to dichotomize the working population into those who do or do not use “illicit” drugs,

While workplace drug screening seems to be increasing, genetic and H N screening appear to be relatively limited. For example, in the Congressional Office of Technology Assessment survey of Fortune 500 companies, only 17 companies stated that they conducted genetic testing in the past five years and five others reported that they were still testing (cited in 57, p. 247). A 1987 survey found that H N testing had been considered by 9 percent of 600 respondent companies, with 23 percent reporting that their top management would favor preemployment H N screening (58). This only says that currently, HIV screening of employees is not widespread; it could yet be implemented on a wider basis.

New Corporate Health Ethic / 99 so that those identified with undesirable lifestyles can be either “rehabilitated” or “screened out.”

THE NEW CORPORATE HEALTH ETHIC Despite distinct rationales, functions, and histories, the recent trends in the development of EAF’s, corporate wellness programs, and drug-screening policies combine to reveal common elements, linkages and values, and social trends. On one level, advocates of these corporate initiatives express widening and constructive concern for the health of employees and recognition of concerns felt by employees themselves. On another level, though, these developments together adumbrate a fundamental shift in accepted corporate jurisdiction over employee health and behavior. The direction of recent growth of these health initiatives constitutes a significant departure from the old corporate health ethic’s distinction between health concerns within the corporate domain, and those beyond it. In the name of health and wellness, the new ethic breaches the line between work and private life. It extends companies’ interests in employee “health habits” and “lifestyle,” without the old regard for whether they occur at work or at home or, indeed, whether they affect work performance in any direct way. Where the old corporate health ethic was narrow and specific to the workplace, a new ethic that casts a wide net for employees’ emotional and physical vulnerabilities is broad and not at all punctilious about limits on its legitimate reach. Both the old and the new ethic are implicit ideologies that outline the contours of corporate responsibilities and entitlements with respect to employees’ health. The current shift to a new health ethic represents a subtle but substantial change in this latent ideology. In part this new corporate health ethic emerges from and interacts with the national ascendance in the United States of a lifestyle theory of health and illness. Decades of epidemiological research, such as the sequence of reports from successive Surgeons General on smoking and health (60, 61), the Framingham Heart Study (62), and the Alameda County Study (63) have specified personal behaviors that are risk factors for disease and premature mortality. The risk-factor paradigm places lifestyle, behavior, and personal habits at the center of thinking about how to promote health and prevent disease (64-66). This approach has shifted the focus of prevention from medical intervention to personal behavior change. To the extent that the new corporate health ethic has a medical or scientific rationale, it resides here. But as Tesh (67, pp. 40-48) and others (e.g., 68, 69) have argued, “science” is far from the entire story; “lifestyle theory” provides ideological justification for political ends. For example, as has often been indicated, emphasis on individual responsibility and self-reliance can divert attention from environmental or social systemic problems and can serve as a rationale for reducing medical care expenditures. Some have suggested that lifestyle theory, with its emphasis on fitness, diet, and other behavior changes, becomes a way of importing middle-class values to other segments of the population (67,p. 47; 70). As corporations erase the boundaries between work and private life, they expand what can legitimately be subsumed under corporate jurisdiction: issues such as smoking, exercise, diet, blood pressure, substance use and abuse, marital and family

100 / Conradand Walsh stress, and social adjustment are incorporated into the business of business. Looking through the occupational medical lens, this shift seems logical and progressive (71, p. 576): The boundary between personal and occupational health concerns is breaking down, as it should. . It makes little sense to draw a sharp line between influences on health on the job and influences from all other human endeavors. Indeed, the only sense is to parcel out responsibility for protection, to ensure that risks and exposures on the job are controlled, and that when occupational disorders do occur that they are properly compensated. Otherwise, it is as illogical to split the worker’s health into that determined by occupation and that determined by the rest of life as it is to split the patient into right and left halves and to assign their care to different physicians.

..

Once the boundaries are broken down, however, one must ask how far corporations (and their medical representatives)will feel entitled to go when a behavior (such as off-hours drug use) or a condition or attribute (such as being overweight) may offend aesthetic or moral sensibilities without diminishing the worker’s ability to function on the job. Ironically it can be said, from one perspective, that companies are finally coming to realize something worker advocates have long contended: that the determinants of health and well-being extend beyond the plant gates. In this light, companies are assuming greater responsibility for the well-being of their employees and providing health-oriented guidance and assistance with life problems. Offering exercise programs, family counseling, or treatment for substance abuse is, on its face, quite laudable. The question is how far this new health ethic will extend. How much of an employee’s lifestyle will the corporation absorb into its jurisdiction? While wellness programs are voluntary and W s rely increasingly on self-referrals (72), drug-screening programs are usually mandatory. And voluntarism is a relative concept in the bureaucratic corporate setting. In the employer-employee context where raises, promotions, or even demotions are part of a long-term contractual relationship, employers need not mandate participation to convey a strong message that involvement in a particular preventive program is normative and expected (23). If subtle coercion is always part of the employment relationship, important questions arise out of the new corporate health ethic. Will corporations begin to selectively promote employees with preferred health and lifestyle profiles? How far can companies push employees to pursue healthier lifestyles? Can “unhealthy habits” become significant factors in hiring and promotion? Can high blood pressure, exercise activities, or family problems figure into evaluations of an employee’s promotion potential? Will there come a time when employers generally will feel free to do as a few already have and make aspects of lifestyle a condition of employment, mandating certain off-the-job behaviors for workers? Will this lead to new forms of job discrimination based on lifestyle and attributed to health? Will lifestyle factors be used increasingly in insurance underwriting, raising premiums or cost-sharing for employees with known risk factors or denying coverage for classes of illness thought to be largely self-imposed? The new corporate health ethic appears ascendent now in U.S.corporations. Evident more in its manifestation than in any articulated policy or conscious ideology, it is by no means universally accepted, but is present in one form or another in many of the nation’s largest and most influential corporations.

New Corporate Health Ethic / 101 UNDERSTANDING THE NEW CORPORATE HEALTH ETHIC Although a complete examination of the “causes” of the new corporate health ethic is beyond the scope of this article, we will evaluate the economic rationale-health care cost containmentwhich is the most common explanation advanced. As an alternative view, we will then posit a more sociological explanation that places the new corporate health ethic in the context of changing models of social control in the workplace. Economic Arguments: The Costs of Medical Care

Inflation in health care costs is increasing at a pace far faster than general inflation, and the impact of these costs on the ability of U.S. corporations to compete in world markets5 is frequently offered as a driving force behind wellness and employee assistance programs (e.g., 30,38). Approximately 30 percent of the health bill in the United States is financed through the employment relationship, and the costs of employee health benefits have risen precipitously in the past two decades. By the 198Os,most large corporations had taken a number of steps that they hoped would slow the rate at which costs were rising. Benefit plans were scaled back and redesigned to include more cost-sharing by employees, outpatient surgery and second surgical opinion programs were promoted, ”utilization management” was widely implemented, health maintenance and preferred provider organization were offered, together with increasingly more elaborate systems of “managed care.” Even so, costs continued to rise. By the end of 1988 it was clear that many firms would have cost increases that year of 10 to 40 percent. The total bill for employee health benefits in 1989 was estimated to be $175 billion (73). In this context of what is perceived as a “crisis” of rising costs, employee assistance, wellness programs, and screening for drugs are often described as part of a multipronged approach to controlling health care costs. In fact, an important justification for investments in these programs is often cost containment and the potential effect on the “bottom line.” If cost containment is the basis on which health promotion (and to a lesser extent, expanded EAPs and drug-screening programs) have been “sold” to corporate America (74), the evidence supporting these claims remains extremely limited and tenuous (44,74,75). Moreover, these cost-related claims contain important conceptual flaws. First, since spouses and dependents normally account for two-thirds or more of corporate health expenditures and retirees account for increasingly large shares of many firms’ health costs, programs seriously directed at affecting the costs of employee health benefits would be marketed aggressively to these populations outside the active workforce, and seldom are. Second, any cost savings from preventing illness in the future by reducing stress, eliminating risk factors, or treating drug abuse are unlikely to be realized immediately except in the rare case. Most potential savings are deferred, yet turnover rates in U S . industry are averaging as high as 50 percent in ten years, so it is unclear how much

’

Because the United States and South Africa are the only industrialized nations without national health insurance, rising health care costs are a special competitive problem for U.S. firms.

102 1 Conradand Walsh individual companies could accrue in cost savings. Third, for the many companies that cover retirees’ health care, keeping future retirees alive longer could actually cost more, not less (46). Fourth, while controlling costs may be a stated rationale, it has been the rare corporation that has made any kind of attempt to track the economic impact of programs. In part this reflects the reality that evaluation research is costly and technically difficult, but in general companies have demonstrated little interest in examining the validity of cost-containment claims. In sum, cost containment appears to be more of an acceptable rationale than an essential cause for the programs that comprise the new corporate health ethic. Rising health care costs may be a necessary element in the backdrop against which these programs have emerged-functioning as a trigger to initiate programs in cost-sensitive firms-but they are not sufficient as an explanatory force. In the larger scope, the new corporate health ethic says more about problems of social control in the workplace and workers’ productivity than about problems of medical care cost control and workers’ health. Sociological Undercurrents: Lifestyle and the Social Control of Work

Economic explanations fall short of accounting for the emergence of a new corporate health ethic. Its deeper sociological significance resides in changes in the corporate environment and recurrent concerns about productivity and an “eroding work ethic.” Over the past two decades, a sizable literature has examined how the social control of work, particularly its organization into increasingly regularized and hierarchical forms, affects the labor process, productivity, and output. Braverman (76) sparked interest in this topic with his analysis of how Taylor’s scientific management and its more contemporary adaptations fragment work and “deskill” workers. Management employs this strategy to regulate the workforce more closely; deskilled workers are “cheaper,” and more expendable. The ultimate goal, of course, is to achieve greater productivity and profitability. Although some of the specifics of Braverman’s formulation have been criticized (e.g., 77, p. 17-24; 78), numerous social scientists have expanded and built on this line of analysis. In particular, Edwards (79) in Contested Terrain elucidates three types of workplace control that have been implemented to manage workers and their productivity. He presents these in historical sequence, although vestiges of the old control strategies coexist with the new. Edward’s theory, in the Marxian tradition, is driven by class conflicts. In this frame, each new form of control attempts to “solve” problems created by its predecessor; each then introduces new problems that require further reform (77, p. 19). For the purposes of our analysis we use Edward’s perspective heuristically, focusing on the historical stages of control he describes, without attempting to extend his theory. In particular we do not address the issue of managerial intent. As Jacoby (80) notes, it is not always clear who benefits from changes in workplace control. In our view, the changes we observe in the social control of work may simply be emerging in the context of a changing society, in which overall mechanisms of social regulation change as the demands of the environment change (81).

New Corporate Health Ethic / 103 The earliest type, traditional or “simple control,” existed when “work tasks [were] organized and controlled by the continuous, direct, ad hoc and arbitrary instructions of the foreman” (79, p. 33). The boss directly controlled working conditions, hiring, firing, wages, and so on. Work was monitored closely by the foreman, and coercion, force, or threats were used to ensure compliance and work performance. A second type of control emerged from attempts to “rationalize” the new assembly line. Managers created “technical control,” by “designing machinery and planning the flow of work to minimize the problem of transferring labor power into labor as well as maximize the purely physical possibilities for achieving efficiencies” (79, p. 112). The labor process and the pacing and sequencing of tasks were mapped out meticulously, so foremen no longer had the same discretion to supervise work; supervision was engineered intr? the production process through technical control. Technical control was limited because workers successfully resisted it and because it was simply not potent enough to overcome the need for their voluntary cooperation. It was vulnerable to disruption in the 1930s, and could not effectively control the worker’s behavior to the degree required. Although forms of technical control are still used in some industries and under some conditions, union opposition and resistance required that a new, less obtrusive and oppressive system of control be developed. This newer mode of control began to achieve dominance in the immediate postWorld War I1 period (for other views, see 80, 82). Technical control yielded to bureaucratic control, which rationalized employment procedures and institutionalized them into the hierarchical structure of the corporation, in “job categories, work rules, promotion procedures, discipline, wage scales, definitions of responsibilities and . . . the impersonal forces of ‘company rules’ or ‘company policy’ ” (79, p. 131). Technical control routinized the technological aspects of production; bureaucratic control “attempted to routinize all the functions of management” (79, p. 131). This included rationalizing employment procedures by using testing and evaluation, finding the “right person for the right job,” creating job ladders with specific classifications, formalizing personnel procedures, and in general, using the carrot of steady employment and systematic promotion. Technical and bureaucratic controls are now being challenged by major changes in the nature of work, workers, and competition, including volatility in the national economy and threats from international competition; declining unionism (9); the transformation to a service economy and the shift in the industrial sector away from bluecollar to knowledge work (83-85); the feminization of the labor force (86,87); and the demands of entrepreneurship or innovation within the business firm (88,89). Edwards’s old “structural” controls, however suited they may have been to the industrial eras in which they emerged, may no longer be adequate to ensure productivity under changing social and economic conditions. With U.S. productivity lagging in the global marketplace (e.g., 90), scholarly and popular attention has moved to innovation-producingand successful companies whose management styles seem to encourage individual responsibility and initiative. The management literature is filled with calls for efforts to win employees’ “commitment” (91) or “involvement” (92) rather than to seek managerial controls. Kanter (89) argues that productive corporations are distinguished by the higher motivation of their

104 J ConradandWalsh

employees and that fostering initiative, independence, and individual responsibility is the key to organizational success. “Individual corporate entrepreneurs,” she argues, are capable of working “through participative teams to produce small changes that can later add up to big ones” (89, p. 35). Rather than sacrificing individual creativity in pursuit of a loyal “organization man,” successful companies are trying to reward employees who can create changes through personal initiative. In this organizational climate, bureaucratic controls may actually stifle innovation. The new efforts to energize individuals and small groups in the workplace are straining the old system of social control. Although some analysts (e.g., 93) have argued that the old forms of control have spawned remodeled syntheses, others see the lineaments of entirely new types of social control. Gryzb for example, interprets innovations such as “quality of worklife” and “quality circles” as efforts by management to “recollectivize” work so that “the creativity of work groups and their ability to enforce work norms” can once again be harnessed in “the service of managerial goals” (94, p. 158). Without elaborating the concept, Gryzb labels these “cultural control.” He and other writers point to the emergence of newer types of social control that operate both intrapsychically and in terms of cultural values and norms. Kunda and Barley (95) suggest that the recent emphasis on “organizational or corporate cultures” is a new managerial ideology aimed at “designing devotion” among workers, devotion to the organization’s mission. The recent attempts to describe alternative corporate cultures (96, 97) all presume that management can somehow engineer culture to enhance performance and productivity. These emergent forms of control are not yet as fully developed or established as older ones, since this is a period in which management is searching for new ways to deal with unprecedented economic and social challenges on a worldwide scale. The present appears to be a period of transition, with new forms of control existing side by side with older ones. It is in this protean context that the new corporate health ethic is taking shape. While not as overtly a managerial ideology as some previous forms of control, the new health ethic may be a harbinger of a new type of control. Virtually all earlier forms of control focused directly on the labor process (77) and the organization of work itself as the locus within which to control workers and productivity. The new corporate health ethic, by contrast, focuses beyond the workplace on the lifestyle of the worker. Attending to the worker’s lifestyle allows corporations to select or shape workers in the name of health, bypassing modem discrimination laws that have limited the employer’s degrees of freedom to select and fire employees. In the changing corporate environment, characterized by accelerating international competition, with Japanese management and productivity touted as superior, managers in the United States are seeking ways to spur productivity. The notion or the “fit corporation” may be more than a metaphor in such a world, where the “downsized” firm needs to be “lean and mean” and where workers with healthy and fit lifestyles are felt to have “a competitive edge” within their firms and on its behalf. Several analysts have suggested that there has been an erosion of the American work ethic in recent decades (98), perhaps especially in the “culture of narcissism” (99). The new health ethic, with its emphasis on disciplined lifestyle and behavior both off and on the job, encourages employees to control themselves, through internalized self-discipline and self-control

New Corporate Health Ethic / 105 (see 100, 101). In a sense, the new corporate health ethic may serve to reinvigorate the flagging American work ethic, by fusing it with the disciplined health ethic. Moreover, innovations such as wellness programs may improve loyalty and morale, both considered vulnerable among mobile workers in unstable modem corporations, no longer able to guarantee a lifetime of employment as many once could. The managerial response to the changing workplace, international competition, and the stagnation of productivity has been diffuse. Managers are groping for strategies to enhance productivity. The claims of human resource personnel and some of the newer health and management professionals who have migrated to the workplace strike a responsive chord, the more so because the programs offered are popular with employees at little cost or risk to the employer. It is unlikely that corporate managers have consciously instituted a new corporate health ethic to shore up control; in fact, many managers and employees agree that wellness programs and EAPs, at least, are just what employees want. But managers may well come to understand the latent benefits attached to these new policies, and continue their support of the health programs for their increment of new control. Two brief anecdotes help to illustrate this point. As part of a larger research project, one of the authors (Peter Conrad) visited wellness programs around the country. In the course of interviews, one vice-president and medical director of a Fortune 500 company noted: “I see health promotion and wellness as attracting and keeping the kinds of employees we want in this company. The. . . guy who is disciplined enough to run 10 or 15 miles a week or exercise regularly or stop smoking and lose weight, has the . . . discipline I want in my employees . . . disciplined, high achievers.” At a conference convened by the other author (Diana Walsh), the corporate medical director of one of the nation’s largest firms, a major sponsor of worksite wellness, placed that program in context (31): The company had a perceived problem with employees’ attitudes toward the firm, toward their supervisors and coworkers and their general satisfaction.When I said I thought we had a program that could show improvements there, the vice presidents gave me a year to pilot the program and try to demonstrate that positive effect on attitudes, with the understanding that if I could they’d support the overall program. We did, and they did, and the program has been expanded without hard data that justifies it strictly on the basis of cost savings.

The new corporate health ethic is about much more than reducing health costs, it is about controlling productivity by shaping values and attitudes of employees toward lifestyle and indirectly toward work through a culture that rewards fitness, striving and strength, and invariably breeds intolerance for signs of weakness. CONCLUSION This article sketches the contours of what may be an important change in the corporate perspective on health. The old distinctions between health concerns on and off the job are being supplemented, and to a degree supplanted, by a new corporate health ethic that embraces employees’ behaviors and lifestyles irrespective of origins or

106 1 Conradand Walsh

impacts. Broad-brush employee assistance, worksite wellness programs, and screening for drugs are all illustrative of the new ethic. It is entirely possible that this new health ethic will contribute to improvements in employees’ emotional and physical health and to morale in the workplace. The programs we discuss address important health problems that account for a large share of the morbidity and mortality in U.S.society. Encouraging employees to quit smoking, to drink less, exercise more, and avoid drugs and the risk of accidents may well create a healthier workforce, even if the impact on health care costs is minimal. Many workers view wellness and assistance programs as desirable benefits, which provide valued services while they symbolize the company’s concern. In many cases managers who institute such programs are responding to employees’ desires or anticipating them. But along with the advantages that may result from these initiatives, the new health ethic contains less obvious consequences: The new health ethic shifts once-sacrosanct boundaries between private life and work life and, in effect, expands the corporation’s jurisdiction into the employee’s leisure time. Concerns about health and lifestyle draw the corporation’s attention to employees’ behaviors and choices off company time, thus into the domain of what has long been considered private life. From a practical standpoint this trend may harbor the potential of increased employer coercion; there is a danger that at some point employers could make wellness and lifestyle a condition of work or promotion. New types of job discrimination could result, based on lifestyle under the rubric of “health.” From a sociological standpoint the significance of the new corporate health ethic is the departure it may represent in workplace social control. In the post-industrial corporation, we may be seeing a shift from social control of the labor process (e.g., 79) to social control of the hearts, minds, and bodies of workers. In the context of the changing demands placed on the workplace, corporate managers may be less stringently controlling the labor process while at the same time trying to shape the values (and lifestyles) of their employees. This is a new means of instilling worker discipline while allowing berth for more individual initiative. Just as health risk factors may be functioning as a socially acceptable marker for companies to use in discriminating between striving and slacking workers, between “them” and “us,” the new corporate health ethic may be a kind of marker indicating who has “the right stuff” in the changing workplace. Rather than the formal rules of the bureaucratic model, emphasis is more squarely placed on “shared values,” which are usually the corporation’s values. Whereas Taylorism standardized the work process, the new corporate health ethic standardizes the worker by selecting and shaping employees on the basis of their lifestyles. Although the health programs are popular among employees, the concepts of “fit” workers and workers who “fit in” are becoming far more encompassing than ever before. This new health ethic also implicitly identifies those without “the right stuff,” making them vulnerable to reduced rewards and marginalization in the company. Corporate goals As an anonymous reviewer of this article noted, “management’s involvement in health-related issues has been quite selective; i.e., programs which emphasize the individual worker’s responsibility for hidher health have been much more popular than those which seek to improve the psychosocial work environment through a real increase in worker control, social support, etc., even though it can be argued that the psychosocial work environment is much more of a management responsibility than workers’ habits off the job.”

New Corporate Health Ethic / 107 remain unchanged-to maximize productivity and profitability; only the means to those ends is being transformed. Our analysis raises a number of questions that we lack the data to answer. To the extent that the new health ethic does signal an emergent form of worker social control, how far can and will corporations go to shape employee lifestyles? To what extent and in what ways is controlling lifestyles truly an effective means of controlling the workforce? As only one piece of an emerging system of corporate control, how does the new health ethic relate to other corporate initiatives, such as quality of worklife programs and deliberate manipulation of “corporate cultures”? How does the new health ethic and its window onto private life dovetail with evidence of movement by corporations into the family realm, beginning with attention to child care, parenting issues and skills, and elder care, and extending how far in the future? Does the new health ethic foreshadow a return to the tenets of welfare capitalism, discredited four decades ago, now cloaked in less overtly paternalistic and perhaps more acceptable garb? Are particular industries or types of firms more likely to adopt these newer forms of control (cf. 102), and if so,what are the characteristics that distinguish them? On one level, promoting health is unassailable; few would think to oppose it. On a deeper level, though, health can be viewed as a moral discourse that reflects particular, deeply ingrained values and consequently can be used as a legitimating vocabulary for instituting changes that might otherwise be resisted. The trajectory and fate of the new corporate health ethic is far from clear, but if it is part of a larger movement toward a more sophisticated and in some ways more invasive and pervasive system of workplace social controls, its impact could ultimately be more far-reaching than workplace health advocates could ever have intended or even imagined.

- The authors thank Phil Brown, Richard H. Egdahl, Sol Levine, Donald W. Light, Susan S.Silky, Carmen Sirianni, Deborah A. Stone, and Irving K. Zola for comments on earlier drafts of this article.

Acknowledgments

REFERENCES 1. Berman, D. M. Why work kills: A brief history of occupational safety and health in the United States.Int. J. Health Sew. 7: 63-87,1977. 2. Smith, B. E. Black lung: The social production of disease. In The Sociology of Health and Illness, edited by P. Conrad and R. Kem. pp. 64-76. St. Martins, New York, 1990. 3. Rosner, D., and Markowitz, G . (eds.). Dying For Work. Indiana University Press, Bloomington, 1987. 4. Walsh, D. C. Corporate Physicians: Between Medicine and Management. Yale University Press, New Haven, 1987. 5 . Starr, P. The Social Transformation ofAmerican Medicine. Basic Books, New York, 1982. 6. Brandes, S. D. American Werfare Capitalism 188&1940. University of Chicago Press, Chicago, 1976. 7. Shah, M., Suurvali. H., and Boutilier, M. Healthier Workers: Health Promotwn and EmployeeAssistancePrograms. D. C. Heath, Lexington, Mass., 1986. 8. Bamard, C. I. The Functions of theExecutive, 30thAnniversary Edition. Harvard University Press, Cambridge, Mass., 1968.

108 J Conradand Walsh 9. Heckscher, C. C. The New Unionism: Employee Involvement in the Changing Corporation. Basic Books, New York, 1988. 10. Somers, H. M., and Somers, A. R. Workmen’s Compensation: Prevention, Insurance, and Rehabilitation of OccupationalDisability. Wiley, New York, 1954. 11. Ashford, N. Crisis in the Workplace. MIT Press, Cambridge, Mass., 1976. 12. Bale, A. Compensation Crisis. Doctoral dissertation, Brandeis University, Waltham, Mass., 1986. 13. Trasko, V. M. Socioeconomic aspects of the pneumoconioses. Arch. Environ. Med. 9: 521-528,1964. 14. Hazlett, T. L., and Hummel, W. H. Industrial Medicine in Western Pennrylvania. University of Pittsburgh Press, Pittsburgh, 1957. 15. Berman, D. M. Death on the Job. Monthly Review Press, New York, 1978. 16. Barth, P. S., and Hunt, A. H. Worker’s Compensation and Work-related Diseases. MIT Press, Cambridge, Mass., 1980. 17. U.S. Department of Labor, Bureau of Labor Statistics. Welfare Work for Employees in Industrial Establishments in the United States. Bulletin No. 250. Washington, D.C., 1919. 18. Lusterman, S . Indusrry Roles in Health Care. The Conference Board, New York, 1974. 19. Walsh, D. C. Employee assistance programs. Milbank Mem. Fund Q. 60: 492-517, 1982.

20. Egdahl, R. H., Walsh, D. C., and Goldbeck, W. B. (eds.). Mental Wellness Programs for Employees. Springer-Verlag, New York, 1980. 21. US. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse and Mental Health Administration, National Institute on Alcohol Abuse and Alcoholism. Fourth Special Report to Congress on Alcohol and Health. U.S. Government Printing Office, Washington, D.C., 1981. 22. Trice, H. M., and Beyer, J. M. Employee assistance programs: Blending performanceoriented and humanitarian ideologies to assist emotionally disturbed employees. Res. Community Ment. Health 4: 245-297,1984. 23. Roman, P. M. Prevention and Health Promotion Programming in Work Organhtwns. North Illinois University Office of Health Promotion, Dekalb, Ill., 1981. 24. Sonnenstuhl, W. J. Inside an Emotional Health Program. ILR Press, Ithaca, N.Y., 1986. 2.5. Blum, T. C. New occupations and the division of labor in workplace alcoholism programs. In Recent Developments in Alcoholism, Vol. 6, edited by M. Gallanter, pp. 205-221. Plenum, New York, 1987. 26. Roman, P. M. Growth and transformation in workplace alcoholism programming. In Recent Developments in Alcoholism, Vol. 6, edited by M. Gallanter, pp. 131-158. Plenum, New York, 1987. 27, Kiefhaber, A. K., Weinberg, A., and Goldbeck, W. B. A Survey of Industry Sponsored Health Promotion, Prevention, and Education Programs. Washington Business Group on Health, Washington, D.C., 1978. 28. Fielding, J. Health promotion and disease prevention at the worksite. Annu. Rev. Public Health 5: 237-265,1984. 29. U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion. NationalSurvey of Worksite Health PromotionActivities. U.S. Government Printing Office, Washington, D.C., 1987. 30. Herzlinger, R. E., and Calkins, D. How companies tackle health care costs: Part III. Harvard Business Rev. JanuaryPebruary 1986, pp. 70-80. 31. Walsh, D. C., and Egdahl, R. H. Corporate perspectives on worksite wellness programs. J. Occup. Med. 31: 551456,1989. 32. Fielding, J. E., and Breslow, L. Worksite hypertension programs: Results of a survey of 424 California employers. Public Health Rep. 98: 127-132,1983. 33. Reza-Forouzesh, M., and Ratzker, L. E. Health promotion and wellness programs: An insight into the Fortune 500. Health Educ. 15: 18-22,1984185. 34. Parkinson, R. S., et al. Managing Health Promotion in the Workplace. Mayfield, Palo Alto, Calif., 1982.

New Corporate Health Ethic / 109 35. Hollander, R. B., and Lengerman, J. J. Corporate characteristics and worksite health promotion programs: Survey findings from Fortune 500 companies. SOC.Sci. Med. 26: 491-501, 1988. 36. Warner, K. E., and Murt, H. A. Economic incentives for health. Annu. Rev. Public Health 5: 107-133,1984. 37. O’Donnell, M. P., and Ainsworth, T. H. (eds.). Health Promotion in the Workplace. Wiley, New York, 1984. 38. Sloan, R. P., Gruman, J. C., and Allegrante, J. P. Investing in Employee Health. Jossey-Bass, San Francisco, 1987. 39. Conrad, P. Health and fitness at work A participant’s perspective. SOC. Sci. Med. 26: 545-550,1988. 40. Conrad, P. Who comes to worksite wellness programs? J. Occup. Med. 2 9 317-320, 1987. 41. &kin, J. M., et al. Factors associated with enrollment in an employee fitness center. J. Occup. Med. 30: 633-637,1988. 42. Bellingham, R., Johnson, D., and McCauley, M. The AT&T communications total life concept. Corporate Commentary 5: 1-13, 1985. 43. Conrad, P. Health and Wealth:-Notes on the Emergence of Worksite Wellness Programs. Paper presented at the wellness in the Workplace Conference, Baltimore, April 1988.

44. Conrad, P. Wellness in the workplace: Potentials and pitfalls of worksite health promotion. Milbank Q. 65: 255-275,1987. 45. Warker, K. E., et al. Economic implications of workplace health promotion programs: Review of the 1iterature.J. Occup. Med. 30: 106-112,1988. 46. Schelling, T. Economics and cigarettes. Prev. Med. 15: 549-560, 1987. 47. Baun, W. B., Bernacki, E. J., and Tsai, S. P. A preliminary investigation: Effect of a corporate fitness program on absenteeism and health care cost. J. Occup. Med. 28: 18-22, 1986.

48. President’s Commission on Organized Crime. America’s Habit: Drug Abuse, Drug Traficking, and Organized Crime. U.S. Government Printing Office, Washington, D.C., 1986. 49. Health Action Managers. Drug testing: Safety boom or moral bust? Health Action Managers 2(1): 1,1988. 50. Steiber, S. Public support of drug testing increases. Hospitals, November 5,1987, p. 92. 51. Dentzer, S. Can you pass the job test? Newsweek, May 5,1986, pp. 46-53. 52. Curran, W. Compulsory drug testing: The legal barriers. N. Engl. J. Med. 316: 318-321, 1987. 53. Panner, M. J., and Christakis, N. A. The limits of science in on the job testing. Hustings CenterRep., December 1986, pp. 7-12. 54. Hoyt, D. W., et al. Drug testing in the workplace-are methods legally defensible? JAM4 258: 504-509,1987. 55. Hafner, K. Testing for drug use: Handle with care. Business Week, March 28, 1988, p. 65. 56. Pollack, R. A bitter pill for epileptics. New York Times, September 3, 1985. 57. Hubbard, R., and Henifin, M. S. Genetic screening of prospective parents and workers: Some scientific and social issues. Int. J. Health Serv. 15: 231-252,1985. 58. Cronin, C. AIDS policy responses vary widely, need private sector input. Business and Health, August 1987, p. 44. 59. Rothstein, M. A. Medical Screening of Workers. Bureau of National Affairs, Washington, D.C., 1984.

60. U.S. Department of Health, Education, and Welfare, Public Health Service. Health Consequences of Smoking: A Report of the Surgeon General. U.S. Government Printing Office, Washington, D.C., 1964. 61. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health. Health Consequences ofSmoking.A Report of the Surgeon General. Centers for Disease Control, Rockville, Md., 1989. 62. Kannell, W., and Gordon, T. (eds.). The Framingham Study. U.S. Government Printing Office, Washington, D.C., 1968.

110 1 Conrad and Walsh 63. Berkman, L., and Breslow, L. Health and Ways of Living. Oxford University Press, New York, 1985. 64. Lalonde, M. A New Perspective on the Health of Canadians4 Working Document. Ministry of National Health and Welfare, Ottawa, 1974. 65. U.S. Department of Health, Education and Welfare, Office of the Assistant Secretary for Health. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. U.S. Government Printing Office, Washington, D.C., 1979. 66. Coreil, J., Levin, J. S., and Jaw, E. G. Life style-an emergent concept in the sociomedical sciences. Cult. Med Psychiatry 9 423437,1985. 67. Tesh, S. Hidden Arguments: Political Ideologv and Disease Prevention Policy. Rutgers University Press, New Brunswick, N.J., 1988. 68. Crawford. R. Individual resmnsibilitv and health mlitics in the 1970s. In Health Care in America, kdited by S. Reverby a n d b . Rosner, i p . 247-268. Temple University Press, Philadelphia, 1979. 69. Stone, D. A. Policy Parahx and Political Reason. Scott-Foresman, Glenview, Ill., 1988. 70. Gillick, M. R. Health promotion, jogging and the pursuit of the moral life. J. Health Polit. Policy Law 9: 369-387,1984. 71. Guidotti, T. L. Exposure to hazard and individual risk: When occupational medicine gets too personal. J. Occup. Med. 30: 570477,1988. 72. Sonnenstuhl, W. J. Contrasting employee assistance, health promotion and quality of

worklife programs and their effects on alcohol abuse and dependents. J. Appl. Behav. Sci. 24: 347-364,1988. 73. Hedgecock, C. Firms forced to cut back on benefits. US4 Today, November 29, 1988,

pp. 1E2B. 74. Warner, K. E. Selling health promotion to corporate America. Health Educ. Q. 14: 39-55, 1987. 75. Kurtz, N. R., Googins, B., and Howard, W. C. Measuring the success of occupational alcoholism programs. J. Stud Alcohol 45: 3345,1984. 76. Braverman, H. Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century. Monthly Review Press, New York, 1974. 77. Salaman, G. Working.Tavistock, London, 1986. 78. Form, W. On the degradation of skills. Annu. Rev. Sociol. 13: 29-+7,1987. 79. Edwards, R. Contested Terrain: The Transformation of the Workplace in the Twentieth Century. Basic Books,New York, 1979. 80. Jacoby, S. M. Employing Bureaucracy: Managers, Unions and the Transformationof Work in American Industry, 1900-1945. Columbia University Press, New York, 1985. 81. Janowitz, M. Sociological theory and social control.Am J. Socwl. 81: 82-108, 1975. 82. Simpson, R. L. Social control of occupations and work. Annu. Rev. Socwl. 11: 415436, 1985. 83. Bell, D. The Coming of Post-IndustrialSociety. Basic Books, New York, 1973. 84. Galbraith, J. K. The New Industrial State. Houghton Mifflin, Boston, 1%7. 85. Drucker, P. Management: Tasks,Responsibilities, Practices. Harper & Row, New York, 1973. 86. Ginzberg, E. The job problem. Sci. Am. 237: 45, November 1977. 87. Johnston, W. B., and Packer, A. E. (eds.). WoryOrce 2000. Hudson Institute, Indianapolis, 1987. 88. Peters, T. J., and Waterman, R. H. Jr. I n Search of Excellence. Harper & Row, New York, 1982. 89. Kanter, R. M. The Change Masters: Innovation for Productivity in the American Corporation. Simon & Schuster, New York, 1983.

90. Productivity Growth: A Better Life for America. Report to the President presented at the White House Conference on Productivity, Springfield, Va., 1984. 91. Walton, R. E. From control to commitment in the workplace. Harvard Business Rev., MarcWAprill985, pp. 77-84.

New Corporate Health Ethic / 111 92. Lawler, E. E. Choosing an involvement strategy. The Academy of Management Executive 2 197-204,1988. 93. Burris, B. Technocratic organization and control. Organization Stud. 1 0 1-22,1989. 94. Gryzb, G. J. Taylored work groups: Managerial recollectivation and class conflict in the workplace. In Research on Social Movemenfs, Conflict and Change, Vol. 6, edited by L. Kriesberg, pp. 142-166. JAI Press, Greenwich, Conn., 1984. 95. Kunda, G., and Barley, S. R. Designing Devotion: Corporate Culture and Ideologies of Workplace Control. Paper presented at the Annual Meeting of the American Sociological Association, Atlanta, Georgia, August 1988. %. Deal, T. E., and Kennedy, A. A. Corporate Cultures. Addison-Wesley, Reading, Mass., 1982. 97. Ouchi, W. Theory Z: How American Business Can Meet the Japanese Challenge. AddisonWesley, Reading, Mass., 1981. 98. Richardson, E. L. (ed.). Work in America: Report of a Special Task Force. MIT Press, Cambridge, Mass., 1973. 99. Lasch, C. Haven in a Heartless World. Basic Books, New York, 1978. 100. Crawford, R. A cultural account of ‘health’: Control, release and the social body. In Issues in the Political Economy ofHealfh Care, edited by J. B. McKinlay, pp. 23-59. Travistock, New York, 1984. 101. Crawford, R. Cultural influences on prevention and the emergence of a new health consciousness. In Care, edited by N. D. Weinstein, pp. 95-115. Cambridge University Press, New York, 1987. 102. Baron, J. N., Jennings, P. D., and Dobbin, F. R. Mission control? The development of personnel systems in U.S. industry.Am. Sociol. Rev. 53: 497-514,1988.

Direct reprint requests to: Dr. Peter Conrad Department of Sociology Brandeis University Waltham, MA 02254