When Knowledge Alone Is Not Enough

“Silicosis remains one of the clearest examples of a preventable occupational disease. Its continued occurrence challenges us to examine not only what we know, but why that knowledge is still applied so inconsistently globally.”

Every occupational disease begins long before the first symptom appears.

It begins with exposure.

More importantly, it begins with a decision.

Some decisions are made during design. Others during procurement, planning, supervision or production. Individually, they appear routine. Collectively, they determine whether exposure is prevented or permitted.

That raises a question I have returned to throughout my career:

If we already know how to prevent many occupational diseases, why do they continue to occur?

When I completed my first NEBOSH qualification in 1992, the profession already understood many of the occupational diseases we continue to confront today. More than three decades later, our scientific knowledge has expanded enormously. We have stronger legislation, improved exposure assessment, better engineering controls, an ever-growing body of research, and more informed professionals.

Yet one challenge remains remarkably unchanged: knowledge does not automatically become prevention.

For me, respirable crystalline silica has become one of the clearest illustrations of that reality. Few occupational hazards have been studied more extensively. The relationship between silica exposure and silicosis has been recognised for generations. Effective controls are well understood. Yet silicosis continues to occur.

Perhaps that should prompt us to ask a different question: not whether we understand the hazard, but why knowledge continues to be translated into practice so inconsistently?

Knowledge is only the beginning.

Throughout my career, I have come to believe that acquiring knowledge itself is rarely the greatest challenge. The greater challenge is what happens after knowledge is acquired.

Knowledge must be understood. It must influence decisions. Those decisions must become effective controls. Those controls must be implemented consistently. Their effectiveness must be evaluated honestly.

Only then does knowledge become prevention.

Professional qualifications, standards and guidance remain fundamental to our profession. They establish the foundation upon which good practice is built. But qualifications do not prevent disease; leadership does, culture does, and decisions do.

Lessons from silicosis

Like many practitioners, I began my career focused primarily on preventing injuries. Working alongside workers, communities and industries affected by silica-related disease fundamentally changed the way I understood prevention.

These were not simply exposure measurements or clinical diagnoses; they were lives permanently altered by hazards that were, in many cases, foreseeable and preventable.

Many years later, during my NEBOSH MRes research, that perspective was reinforced through in-depth academic enquiry. Generating evidence is only the beginning; the true measure of progress is our ability to translate that evidence into consistent prevention. That principle has shaped my professional thinking ever since.

Occupational disease rarely begins at diagnosis. It begins much earlier; in design, in procurement, in leadership, in organisational culture, and sometimes, in the acceptance of risks we already know should not exist.

The illusion created by time

Many occupational diseases develop over years or decades, but that delay creates a dangerous illusion. Projects finish, contracts end, managers move on, organisations change. The commercial benefit is realised immediately, but the health consequences emerge much later.

Latency should never become an excuse for delayed accountability; every uncontrolled exposure represents an opportunity for prevention that has already been lost.

Perhaps we should therefore ask different questions:

• Who recognised the risk?
• Who had the authority to act?
• Why was action delayed?

Shared responsibility must never become diluted responsibility. Remember that responsibility can be delegated, but liability cannot.

Leadership beyond compliance

Occupational disease prevention is often described as a technical discipline, but I believe it is equally a leadership discipline:

• Designers influence exposure before work begins…
• Procurement teams influence exposure before materials arrive…
• Executives determine whether occupational health is regarded as an investment or a cost…
• Managers shape organisational priorities…
• Supervisors shape everyday behaviour…
• Occupational health professionals and occupational hygienists help organisations understand risk, and leadership determines whether that understanding becomes action…

Silicosis does not continue because science has failed - it continues because knowledge is still applied inconsistently.

Looking beyond the workplace

Workers do not leave their health at the workplace gate; they return home to families and communities. Increasingly, occupational health intersects with environmental health, public health, and the broader principles of One Health. Perhaps our professional boundaries have become more rigid than the pathways that influence health.

Healthy workplaces create healthier communities; that may be one of the profession’s most important responsibilities in the decades ahead.

The future of prevention

Silicosis is only one example. The same questions apply to occupational cancer, asbestos-related disease, diesel exhaust, welding fume, noise-induced hearing loss, psychosocial health and many of the emerging challenges facing the modern workforce.

The question is no longer whether we understand these hazards; the question is whether we are prepared to apply what we already know. The workers who develop occupational disease twenty years from now may already be experiencing the exposures that will shape their future health. Whether those exposures continue depends upon decisions being made today.

Perhaps the future of occupational disease prevention will not be defined by the next scientific discovery; perhaps it will be defined by our willingness to ensure that knowledge consistently becomes action. Because the true measure of professional competence is not what we know, it’s the extent to which that knowledge prevents harm.

So, what can practitioners do today?

• Find the exposure, not just the hazard. Identify where workers are actually exposed to substances or conditions that can cause long-term ill health. Ask whether exposure is being eliminated or controlled at source, rather than simply documented in a risk assessment or the conventional and potentially ineffective PPE catch-all route.
• Look upstream. Consider whether decisions about design, procurement, materials, equipment, and work methods create exposures that could have been prevented before work began.
• Test whether controls really work both effectively and efficiently. Do not assume that a control is effective simply because it exists. Observe the work, speak with workers and, where appropriate, use exposure monitoring or health surveillance to help verify effectiveness.
• Give significant health risks an owner. Ask: Who recognized the risk? Who has the authority to act? What action is required, and by when? Shared responsibility should never become diluted responsibility. Remember that responsibility can be delegated but liability cannot. Those with responsibility must have autonomy to act.
• Act on one preventable exposure today. Identify one known occupational health risk in your workplace and one practical intervention that could reduce or eliminate the exposure. Assign responsibility, implement it and check that it worked.

A final challenge:

If a worker develops an occupational disease 10 or 20 years from now, what exposure occurring in your workplace today might have contributed to it, and what could you do now to prevent it?

About the Author

Dr. Nayab Sultan is a NEBOSH MRes alumnus and Founder & CEO of Global HSE Consulting Limited. Over more than 35 years, he has worked internationally across occupational health, occupational hygiene and workforce health systems, with a particular focus on the prevention of occupational disease. He holds nine international expert roster appointments, serves as Co-Convenor of the ISO/TC 283 Developing Countries Coordination Group, and is a Research Fellow at the University of Birmingham. In 2025, he received the Society of Occupational Medicine’s award for Outstanding Contribution to the Development of Occupational Health Globally.