Safety Net | January 2020

The Safety Net C O N S U LTA N T S

▪

DESIGNERS

▪

ENGINEERS

IT’S ALWAYS SAFETY FIRST. ▪

JANUARY 2020

CONSTRUCTORS

VOLUME 14 ISSUE 1

When it Comes to Skiing, Don’t Take a Crash Course National Safety Council | 12.23.2019

Many of us remember the day we heard Sonny Bono, a California congressman and half of the singing duo, Sonny and Cher, died while on a ski trip with his family in Lake Tahoe, Calif.

Bono was no amateur when it came to skiing. In fact, CNN quoted a family spokesperson as saying Bono was a “very proficient skier” and an “athletic guy.”

He had been skiing on those same slopes for more than 20 years. Media reports said that Bono was skiing alone when he slammed into a tree at a high rate of speed. The New York Daily News reported he skied off the main trail and was likely weaving in and out of trees in fresh powder when he was killed.

HONE YOUR SAFETY SKILLS Skiers and snowboarders, no matter how experienced, should never ski alone. Nor should they ski off the designated trails. Experts believe Bono was killed on impact, but in many cases an injured skier can be saved if someone is there to help.

SAFETY FIRST. Austin employees have worked 3,141,825 hours without a Lost Time Accident through 10/2019.

According to the Consumer Product Safety Commission, snowboarding caused 54,188 emergency department visits in 2011. Excess speed, loss of control and collisions with stationary objects, like a tree or lift tower, are the most common factors associated with fatalities.

National Safety Council advises all skiers and snowboarders take the time to review proper skills and safety techniques.

• Get in shape for the season, and not just the week before a ski trip; a regular exercise routine will help reduce fatigue and injury • Beginners should invest in proper instruction, including learning how to fall and get back up; experienced skiers should take a refresher course • Always know the weather conditions before heading to the slopes; time of day can also affect visibility and make obstacles difficult to see • Give skiers in front of you the right of way; they most likely can’t see you • If you have to stop, stop on the side of a run, not in the middle • Look both ways and uphill before crossing a trail, merging or starting down a hill • Use skis with brakes or a snowboard with a leash to prevent runaway equipment • N ever ski on closed runs or out of boundaries because these areas are not monitored and there is no way to know what the snow conditions are; a rogue skier could even cause an avalanche

BE SAFE WITH PROPER GEAR Helmets reduce head injuries. However, even though helmet use has increased over the years, traumatic brain injuries still can occur with helmet use. Severe injury and death is prevented by avoiding risk-taking behaviors.

Skiers and snowboarders also should select quality equipment. Improperly fitted or misadjusted gear can cause injury, so it’s best to ask for expert advice when purchasing and fitting boots, bindings and skis. While trendy ski apparel looks good on the slopes, clothing should be functional. Wear bright colors, dress in layers and make sure outerwear is made of fabric that is not only water repellent, but slide-resistant.

Following these basic safety tips will go a long way toward ensuring that next powder run isn’t your last.

2

Enjoy a Safe Holiday Season National Safety Council | 11.22.2019 CO poisoning is entirely preventable. Protect yourself and your family by learning the symptoms of CO poisoning and how to prevent it.

When winter temperatures plummet and home heating systems run for hours the risk of carbon monoxide (CO) poisoning increases.

Every year, at least 430 people die in the U.S. from accidental CO poisoning. Approximately 50,000 people in the U.S. visit the emergency department each year due to accidental CO poisoning. There are steps you can take to help protect yourself and your household from CO poisoning.

CO is found in fumes produced by furnaces, kerosene

CO POISONING PREVENTION TIPS • Change the batteries in your CO detector every six months. If you don’t have a battery-powered or battery back-up CO detector, buy one soon.

• Have your heating system, water heater and any other gas, oil, or coal burning appliances serviced by a qualified technician every year.

• Keep vents and flues free of debris. Debris can block ventilation lines.

• Never leave the motor running in a vehicle parked in an enclosed or partially enclosed space, such as a garage.

• Never run a motor vehicle, generator, pressure washer,

heaters, vehicles “warmed up” in garages, stoves,

or any gasoline-powered engine less than 20 feet from

lanterns, and gas ranges, portable generators, or by

an open window, door, or vent where exhaust can

burning charcoal and wood. CO from these sources can

vent into an enclosed area.

build up in enclosed or partially enclosed spaces. People and animals in these spaces can be poisoned and can die from breathing CO.

HOW TO RECOGNIZE CO POISONING The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. People who are sleeping or who have been drinking alcohol can die from CO poisoning

• Never use a charcoal grill, hibachi, lantern, or portable camping stove inside a home, tent, or camper.

• Never run a generator, pressure washer, or any gasoline-powered engine inside a basement, garage, or other enclosed structure, even if the doors or windows are open.

• If you suspect CO poisoning, call 911 or a health care professional right away.

before ever having symptoms.

CO poisoning is entirely preventable. You can protect

CO poisoning is entirely preventable. Protect yourself and

yourself and your family by learning the symptoms of CO

your family by learning the symptoms of CO poisoning

poisoning and how to prevent it.

and how to prevent it.

3

How to Use Ergonomics in the Workplace for Maximum Health Benefits OH&S | 12.10.2019 by Beth Meakin How do you prevent the onset of MSDs?

The average office worker spends an average of 1,700 hours per year in front of the computer screen—that makes up

Most of us tend to position

over 70 days of sitting at a desk. Most of

ourselves in a way that

us tend to position ourselves in a way that

makes us feel most

makes us feel most comfortable because

comfortable because what

what feels best must be best, right? Well, this is not true—failing to take ergonomic

The risk of musculoskeletal disorders increases with age, but people of any age can experience them due to other conditions, like bad posture. The best way to prevent the onset of musculoskeletal

feels best must be best, right?

disorders in the workplace office

Well, this is not true—failing

environment is with ergonomics.

precautions when it comes to sitting for a long period of time can result in several

to take ergonomic

musculoskeletal disorders and seriously

precautions when it comes

impact our health.

Every year, over 6.9 million working days are lost as a result of musculoskeletal

to sitting for a long period of time can result in several musculoskeletal disorders

disorders and generally progress over a

and seriously impact

period of time, especially in those who

our health.

tend to endure prolonged sitting positions

What is ergonomics?

Ergonomics is the process of designing or arranging furniture, products, systems and devices so that they fit the people that use them to minimize the risk of injury or harm as a result. The aim is to create a comfortable, safe and productive workspace by bringing together health

or repetitive motions.

and design, with positioning and

The symptoms of MSDs include recurrent pain, stiff joints,

adjustment based on thing such as:

shooting pains, swelling, dull aches and loss of strength.

• Body size

• Skill

• Height

• Speed

• Strength

• Sensory abilities

They can affect any major part of the musculoskeletal system, but most frequently affects the back, neck and shoulders. Research has found that lower back pain is the world’s most common work-related disability.

(vision, hearing)

4

How to do apply the correct ergonomics?

Every individual is different, so the best way to educate and apply correct ergonomics is with a personal workstation assessment. There is no ‘one-size-fits-all’ ergonomics solution, so it’s about investigating each person to determine his or her requirements. This can be

Keyboard and mouse. The computer mouse should be comfortably within reach of the user, with the forearms, wrists and mouse parallel to the desk. Wrists should be in a neutral position and is best assisted by a wrist or palm support. The keyboard should be slightly tilted and also at a comfortable distance.

done by a specialist, or a designated staff member who

Other accessories. Any equipment used by the employee

takes the appropriate training.

should not require strained, repetitive or awkward postures

Chair adjustments. An employee should be shown how to adjust his/her chair, which needs to be at a comfortable height with feet lying flat on the floor and knees as at a 90° angle. The individual’s back should be supported by the back and seat pan, preferably with a chair with lumbar

or motions. This includes phones, headsets, staplers, and calculators for example.

What to do if you are experiencing a musculoskeletal disorder

support. The user should sit up straight in the seat, and be

If you are experiencing symptoms of a musculoskeletal

encouraged to take regular breaks away from the screen

disorder such as back, neck or shoulder pain, then

and walk around the office, even if this is to the kitchen to

you should visit a GP. You will likely be referred to a

make the tea round.

physiotherapist or specialist, but this can take weeks

Computer monitor. An employee’s screen should be adjusted so that eyes are level or slightly higher than the top of the monitor, to limit the requirement of excessive

and even months. Why not visit a private GP, who is able to fit you in around your schedule, including same-day appointments?

neck movements. It should also be positioned at an armslength away from the user.

5

Preventing Cold Stress weeklysafety.com | 12.20.2019 Cold stress isn’t just a hazard for outdoor workers. What are the best ways to prevent cold stress injuries and illnesses and what is the best clothing to wear in cold environments?

Anyone working in a cold environment may be at risk for

RISK FACTORS FOR COLD STRESS INCLUDE: • Overexposure to cold temperatures • Increase wind speed, and the wind chill effect

cold stress. This could include an indoor workplace like cold

• Wet clothing and/or wet skin

storage or an outdoor job in construction or agriculture.

• Dressing improperly for the weather

Prolonged exposure to cold and/or freezing temperatures while on the job may cause serious health problems such as trench foot, frostbite and hypothermia. In extreme cases, exposure to cold temperatures can lead to death.

• Exhaustion • Health conditions such as high blood pressure, diabetes or asthma

Although OSHA does not have a specific standard

• Poor physical conditioning

that covers working in cold environments, under the

• Inadequate training on how to work safely in

Occupational Safety and Health Act (OSH Act) of 1970, employers have a duty to protect workers from

cold temperatures

recognized hazards, including cold stress hazards, that are

IMPORTANT TIPS TO PREVENT COLD STRESS

causing or likely to cause death or serious physical harm in

• Wear proper clothing for cold, wet and

the workplace.

windy conditions.

• Take frequent, short breaks in warm, dry shelters.

6

• Schedule work for the warmest part of the day.

• Avoid exhaustion or fatigue.

• Keep extra clothing handy in case clothes get wet.

Michigan Worker Death Notification MIOSHA | 11.12.2019

• Drink warm, sweet beverages and avoid drinks with caffeine or alcohol.

• Eat warm, high-calorie foods.

• Use the buddy-system - work in pairs so that one worker can recognize the danger signs.

• Stay dry in the cold because moisture or dampness, even from sweating, can increase the rate of heat loss from the body.

Dressing properly is extremely important to preventing cold stress. Wear at least three layers of loose fitting clothing. Layers provide better insulation.

• An inner layer of thermal wear, wool, silk or synthetic (polypropylene) to keep moisture away from the body.

• A middle layer of wool or synthetic to provide insulation even when wet.

• An outer wind and rain protection layer that allows some ventilation to prevent overheating.

Tight clothing reduces blood circulation and warm blood needs to be circulated to the extremities.

Other important clothing that can help prevent cold stress:

A 40-year-old laborer/subcontractor was using a bobcat to remove snow when the pedals became frozen on the machine.

The bucket on the bobcat was in the raised position and the machine was off.

The laborer/subcontractor began to play with the pedals on the machine when the bucket came down suddenly pinning him between the arm of the bucket and the framework of the machine.

• Insulated coat/jacket (water resistant if necessary) • Knit mask to cover face and mouth (if needed) • Hat that covers the ears.

• Insulated gloves (water resistant if necessary, to protect the hands • Insulated and waterproof boots to protect the feet If employees are working in cold environments, indoors or outdoors, then they should have access to cold stress prevention safety training and it’s also a great topic for a safety meeting.

7

Long Commutes Stressing Out U.S. Workers, Survey Shows National Safety Council | 12.02.2019

Menlo Park, CA — Half of workers say their commute to

Miami had the most respondents reporting stressful

and from the office stresses them out, and 45% think their

commutes, with San Diego, Austin, Los Angeles and

trip is too long – up from 30% in 2017, results of a recent

Phoenix rounding out the top five, respectively.

survey show.

Results of another Robert Half survey that sampled more

Researchers, on behalf of staffing firm Robert Half,

than 2,800 senior managers at organizations with at least

surveyed 2,800 adult office workers in 28 major U.S. cities.

20 employees show that about 43% of the respondents

The respondents’ average commute time was around 48.4

said their company offers flexible scheduling to help

minutes, and nearly 20% said they spend at least an hour

workers avoid peak traffic times, and another 40% said

traveling to work.

their organization offers telecommuting.

Respondents in the nation’s capital reported the longest

“When workers have difficult commutes into the office,

average commute (65.8 minutes), followed by workers in

their engagement and productivity can suffer the rest of

New York (60.8) and Houston (59.2). Workers in Los Angeles

the day,” Paul McDonald, senior executive director for

reported most often that their commute was too long

Robert Half, said in a Nov. 5 press release. “This may affect

(65%), followed by employees in Austin, TX, and Miami

staff satisfaction and retention in the long run. With the

(62% a piece).

current employment environment favoring job seekers, organizations can’t afford to ignore the issue and lose their best team members to other opportunities.”

8

OSHA Issues Temporary Enforcement Policy After Crane Operator Certification Organization’s Accreditation Lapses

OSHA News Release Region 1 U.S. Department of Labor | 12.13.2019 Massachusetts Court Sentences Contractor Convicted for Manslaughter And Witness Intimidation in Deadly 2016 Trench Collapse

NationAL | 12.04.2019

BOSTON, MA – The Suffolk County Superior Court in Boston, Massachusetts, recently sentenced Atlantic Drain Service Company Inc. owner Kevin Otto to two years imprisonment on each of two counts of manslaughter, to run concurrently, and three years of probation for witness intimidation. The court’s action follows a U.S. Department of Labor Occupational Safety and Health Administration (OSHA) investigation into a trench collapse on October 21, 2016, that led to two fatal injuries of two employees.

The witness intimidation charge resulted from the defendant’s attempts to mislead OSHA during the investigation of the collapse. The court also fined Atlantic Drain $1,000 for each count of manslaughter,

Washington — OSHA has issued a temporary enforcement policy for the construction industry after being informed by the Sanford, FL-based Crane Institute Certification that the organization no longer is accredited by a nationally recognized accrediting agency, as required under section 1926.1427(d) of OSHA’s Cranes and Derricks in Construction Standard.

In a Nov. 25 memo addressed to regional administrators and State Plan designees, Scott Ketcham, director of OSHA’s Directorate of Construction, writes that many employers “may have acted in good faith by obtaining crane operator certifications from CIC that

and $5,000 for witness intimidation, totaling $7,000.

“Employers that display willful disregard for employee safety and/or obstruct, mislead or otherwise interfere with an OSHA inspection will face serious consequences,” said OSHA Regional Administrator Galen Blanton in Boston, Massachusetts. “The court agreed Kevin Otto knew what safeguards were needed and required to protect his employees, yet he chose to ignore his responsibility to provide them. The result was the loss of two men.”

“The U.S. Department of Labor thanks the Suffolk County District Attorney’s Office which prosecuted the case, with assistance from the Department’s Occupational Safety and Health Administration, Office of Inspector General and Office of the Solicitor, as well as the Boston Police Homicide Division,” said the U.S. Department of Labor’s Regional Solicitor Maia Fisher, in Boston.

they believed would comply with OSHA’s

The judge’s decision also stated Atlantic Drain and any company

requirements,” adding that, “Where such good

owned and operated by Otto may not employ, directly or indirectly,

faith is found, employers should not be cited for

anyone working in a trench deeper than four feet during his three-

violating the operator certification requirement

year probation.

of 29 CFR 1926.1427(d).”

Under the Occupational Safety and Health Act of 1970, employers

Ketcham warns that this policy will apply only

are responsible for providing safe and healthful workplaces for

until the certification expiration date. OSHA will

their employees. OSHA’s role is to help ensure these conditions

not accept CIC crane operator certification

for America’s working men and women by setting and enforcing

issued on or after Dec. 2 “as evidence of

standards, and providing training, education, and assistance. For more

compliance” with federal regulations.

information, visit https://www.osha.gov.

The memo states OSHA will revisit this temporary

The mission of the Department of Labor is to foster, promote, and

enforcement policy when CIC provides evidence

develop the welfare of the wage earners, job seekers, and retirees of

that it is back in compliance, which the institute

the United States; improve working conditions; advance opportunities

expects to occur “within the next few months.”

for profitable employment; and assure work-related benefits and rights.

9

Facevalue: Dump Truck Operator Fatally Electrocuted By High-Voltage Line National Safety Council | 10.27.2019 Case report: #18KY024 Issued by: Kentucky Fatality Assessment and Control Evaluation (FACE) Date of incident: June 22, 2018 On the day of the incident, a 61-year-old dump truck owner-operator was transporting crushed rock to fill a sinkhole. The victim raised the bed of the dump truck, which contacted high-voltage power lines, causing a rear tire to catch fire. As the dump truck operator attempted to exit the vehicle, he stepped off the metal running board while holding onto the side of the truck. Because he was in contact with the ground and the electrified dump truck, the victim became grounded, completed the circuit and was immediately electrocuted. The victim’s co-worker and employees from the primary construction company were able to pull him away and douse him with a fire extinguisher to put out the flames on his body.

The electrical current had entered and exited his feet and hands. At the time of the incident, the company consisted of only two employees: the victim and his brother-in-law. As a result, no written or verbal safety or training programs were in place. The two men relied on their experience in the field to maintain their safety.

To prevent future occurrences: • Perform a hazard assessment before beginning work to be aware of the hazards in the immediate area.

• Require drivers to have a spotter when working around electrical lines.

• Have motor vehicles maintain a safe working distance from high-voltage lines.

• Communicate to workers that when a vehicle contacts electrical power lines, best practice is for passengers to remain in the vehicle and call 911.

10

The Human Aspect Of The Latest Bls Injury Numbers JJ Keller | 12.10.2019 by Travis Rhoden

Experts weigh-in, offer practical solutions

The numbers, overall, did not increase over the past year

Nearly three million workers were injured on the job last

and remained at the lowest number since 2002 — a fact

year, according to data released by the Bureau of Labor

that OSHA pointed out when asked about the data.

Statistics (BLS). That’s three million fathers, mothers, brothers,

However, the numbers didn’t decrease for the first time

sisters, sons, daughters, spouses, coworkers, and friends

in several years, which is signaling trouble to some safety

who were injured, in many cases severely enough that they

advocates.

couldn’t go to work for a period of time.

That’s the human aspect of the data.

In fact, one could argue that if three million workers were actually injured, at least double that number of people were impacted. When a wife is injured on the job, the kids and the husband suffer, too.

And, so do employers.

In many cases, when an experienced worker is off work because of an injury, a less-experienced worker must take over. This can lead to a noticeable drop in production — not to mention any OSHA recordability or workers’ compensation issues that arise from the injury.

...continued on next page 11

“Stagnant injury rates are unacceptable and a clear call

“All of those are important and we have regulations related

to employers nationwide to take a harder look at their

to those. But, when you look at more of the injuries these

approach to workplace safety and health,” said ASSP

days, they are soft tissue,” Stegall says.

President Diana Stegall, CSP, CFPS, ARM, SMS, CPCU.

“We’re not addressing those because there’s no regulation.”

“Incidents that harm workers are occurring far too often in every industry. Most occupational injuries and illnesses are preventable given today’s technologies and proven safety and health strategies.”

Former OSHA leader, and current Professor at the George Washington School of Public Health, Dr. David Michaels, also expressed concern over the current numbers.

“I am concerned about the injury numbers — the overall high numbers should be unacceptable to the nation,” he said. “We know the figure of three million injuries annually is an underestimate. We should be doing more to lower the rate, but instead it is rising — that is deeply concerning.”

Dr. Michaels points to a series of studies commissioned by the BLS, which have concluded that injuries reported by employers do not match up to data in workers’ compensation and other systems, leading to a “significant portion” of injuries that aren’t counted in the BLS data.

This does not mean that employers are willingly underreporting to the BLS, however. The agency notes that there are many potential causes, including confusion around the different systems that are in place, such as workers’ compensation and OSHA recordability. Further, as an annual survey, the BLS data may also fail to capture injuries or illnesses with a long onset or latency period.

But, what we know for certain is that overall injury rates stalled last year.

Of particular concern, are the rates in the retail industry.

Rather than simply stagnate, the injury rate in that industry actually increased — for the first time since BLS began collecting this series of data in 2003.

“Retail was a surprise,” according to former OSHA area director, John Newquist, “I think the newer employees are older. They are more easily subject to ergo injuries.”

In fact, sprains, strains, and tears accounted for 34 percent of all the cases with days away from work in 2018.

Contusions and tendonitis made up another nine percent.

To ensure all injury causes are accounted for, Stegall suggests that employers look not only at hazards and compliance, but also at the risks that are present.

This is something that was a noticeable point of emphasis in last year’s publication of the ISO 45001-Safety and health management systems standard, the first-ever international standard for managing safety systems. Before that, most existing industry standards, such as the OHSAS 18001 standard, focused on identifying and controlling “hazards.”

The new ISO 45001 standard, as well as the newly published ANSI Z10 safety management standard, place a heavy focus on “risk.”

This means, among other things, that employers s hould proactively look at what’s actually going on in the workplace.

“We only see the work as we’ve imagined it should be, not necessarily as it’s performed,” Stegall says. “We’re not getting the feedback from the workers who do the work day-in and day-out.”

She notes that even in incident investigations, often, employers stop once they figure out what went wrong.

Rather than asking the worker to “help me understand what was going on — help me understand the decision that you made,” employers often only see things from one perspective.

“It’s really easy to look back after the fact and say, ‘we should have done X, Y and Z,’” Stegall says. However, she says many employers stop short of actually getting to the heart of why the worker made the decision they did.

She suggests asking questions to get information from the

Lack of focus on ergonomic issues may be partly to blame

worker’s perspective on what was going on and why they

for the overall injury numbers.

made the decision they did based on the information they

Stegall suggests that a lot of processes currently in place

had available at the time.

have been aimed at typical serious injuries, such as those

Another potential cause for the high injury numbers may be

from caught-in and struck-by hazards. These are areas

lack of a dedicated safety professional.

where OSHA has standards. However, that may mean some hazards are being overlooked.

12

“I am seeing HR trying to handle safety without basic safety

systems and adopt strategies to better protect worker well-

training like an OSHA 511 class,” said Newquist.

being on and off the job. Both can help companies create

Additionally, employers sometimes have programs that are

true safety cultures by shifting from compliance-based

not implemented fully — they are made for compliance,

approaches to risk-based programs.

but not necessarily for the way the work needs to be done.

In addition, organizations should use next-generation

Further, employers must ensure that the programs that are

approaches such as Total Worker Health (a term created by

implemented are maintained.

“Anything from a safety perspective should be living and breathing — it’s never just a one and done,” Stegall says.

“The world of work is changing so quickly, we can’t just say ‘it’s done; it’s on the shelf’. We have to look at that again. It really should be taking a look at things on a regular basis.”

She recommends employers regularly look at such things as the following for potential changes requiring program updates: • Equipment • Processes • Chemicals

NIOSH) to move beyond traditional wellness initiatives and take a broader view of worker well-being.

“There are widespread benefits when a business makes occupational safety and health a priority,” Stegall said.

“Not only do workers return home safe to their loved ones, but quality and productivity flourish, helping organizations achieve sustainable growth, meet social responsibilities, and be viewed as employers of choice.”

“WE WANT TO SEND THEM HOME BETTER THAN WHEN THEY SHOWED UP” One thing Stegall urges employers to think about is that when they hire an employee they aren’t just hiring “one part” of the worker — they are hiring the total worker. If an

• Employee-base

employee is already susceptible to back problems from an

Even something as simple as a PPE program can be

off-the-job issue, putting in ergonomic aids makes sense —

overlooked, which can lead to improper protection, Stegall notes.

“Are we buying personal protective equipment that properly fits the people that we have in our worksite currently — versus 5 or 10 years ago (when the assessment

not only will it prevent the worker’s back from becoming more of a problem for the company and the worker, but it likely will lead to better productivity and, through training and other techniques, possibly a better home life for the worker, which will ultimately benefit the company.

was done)?”

When employers can help an employee improve his health,

WHAT IS THE OSHA 511 COURSE?

theory behind the Total Worker Health movement. It’s also a

The OSHA 511 Occupational Safety and Health Standards

the benefits reach far beyond the workplace, which is the perfect example of the positive side of the human aspect

for General Industry course is a voluntary course offered

of workplace safety.

through authorized OSHA Training Institute Education

Key to remember: Injury and illness numbers represent

Centers. The course covers OSHA standards, policies, and

real impacts to workers’ lives and employers’ productivity.

procedures in general industry with special emphasis on

Employers should remember they are hiring the “whole”

those areas in general industry which are most hazardous.

workers, not just a part. Safety systems with employee

EXPERT ADVICE TO KEEP YOUR WORKFORCE SAFE

feedback are key, as well as ergonomic interventions.

ASSP, which represents more than 39,000 occupational safety and health professionals worldwide, recommends that employers implement safety and health management

13