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Help Your Employees Fight Illness

Relatively minor illnesses—such as asthma, arthritis, or allergies—can have a huge, though largely invisible, impact on how well employees perform. This Harvard Business Review excerpt outlines how employers can reduce the problem of "presenteeism."

Editor's note: Employers worry a lot about absenteeism, but new research suggests a bigger threat to productivity is "presenteeism": sick workers who show up at work but are not fully functioning. U.S. companies may lose $150 billion (yes, that's billion) annually because of presenteeism, according to some estimates. This Harvard Business Review excerpt details what employers can do about the problem.

Whatever the shortcomings of current measurement tools and research, most people agree that presenteeism represents a problem for employers: When people don't feel good, they simply don't do their best work.

It's one thing to show that there's a problem, though, and another to demonstrate that there's something you can do about it—and, if something can be done, that the benefits will justify the investment. A central aim of presenteeism research is to identify cost-effective measures a company can take to recover some, if not all, of the on-the-job productivity lost to employee illness.

The first step, clearly, is making your managers—and yourself—aware of the problem. Buzz Stewart recalls doing research in the late 1990s, when he was a professor of public health at Johns Hopkins University, on the impact of migraines on productivity. He was initially skeptical about the magnitude of his own findings. Then people at the university started telling him about how migraines affected their work. The big surprise, though, came several years later at a party, where he was chatting with the migraine study's project manager. She told him that about twice a month, she would close her office door as soon as she got to work, turn off the lights, and put her head on her desk. The problem: migraine headaches, of course. "Here I was, a 'national expert' on the subject," he says, "and I wasn't even aware of what was going on with my own staff."

The next step involves getting to know the particular health issues facing your employees. This might entail a formal study, but to begin with, you could simply look at your workforce with health issues in mind. Debra Lerner, at Tufts University, puts it this way: "An employer might say, 'We're a company with a workforce of mostly women, and our profitability depends on excellent customer service. Women are more likely than men to suffer from depression, and depression can affect customer relations. So maybe we should be doing something about this.'"

Educating employees is also crucial. You may want to set up programs to ensure that illnesses aren't going undiagnosed because employees don't realize they have a problem ... or that illnesses aren't being misdiagnosed. Comerica's study of irritable bowel syndrome revealed that some employees had for years unsuccessfully sought help from as many as five or six doctors, who incorrectly diagnosed the condition; in a misguided effort to ease their pain, many workers had even undergone an exploratory appendectomy, hysterectomy, or other type of surgery.

One-shot education isn't going to be effective.
— Harris Allen, consultant

It's also helpful to teach employees how to better manage their illnesses. A recent education program at Lockheed Martin for arthritis sufferers gave explanations of treatment options and advice on making physician visits more productive. Comerica sponsored a series of hour-long Lunch and Learn sessions led by a gastroenterologist, which focused on things employees can do, like changing their diet and reducing stress, to relieve the symptoms of irritable bowel syndrome. Such programs usually emphasize the importance of regularly taking one's medications.

These steps seem simple, but the challenge of improving health education is far from trivial, as findings from the International Truck and Engine allergy study highlight. The company had augmented its traditional ways of relaying information to employees (newsletters, brochures, and bulletin board displays) with Web pages and on-site consultations with allergists. But a follow-up study revealed that the interventions hadn't boosted the relatively small proportion of allergy sufferers—about 25 percent—who took the new generation of non-sedating medications. "One-shot education isn't going to be effective," says consultant Harris Allen, who led the research with William Bunn, MD, vice president of health, safety, and productivity at the company. "Even when potential benefits take the form of such low-hanging fruit as getting people to switch to a more effective medication, you need to overcome such motivational barriers as a reluctance to try something new or simple inertia."

Spending to save
Ultimately, improving productivity by improving employees' health takes more than relatively low-cost education programs. It requires paying for new or better medical treatment, whether medication for allergies, counseling for depression, or tests to determine the cause of chronic headaches. Certain medications—for example, those used to treat allergies, migraines, asthma, and depression—have been found to significantly improve productivity, according to a survey of recent research on the subject.2

So far, though, there have been only a few studies showing that productivity gains completely offset the direct cost of providing the medications. One such study looked at the effect of allergies on Bank One's call center service representatives and concluded that productivity improvements would indeed be more than worth the cost of providing the allergy medications. Even the more general findings—that productivity increases when workers with health problems take appropriate medications—suggest that a company's pharmacy costs should be viewed at least in part as an investment in workforce productivity. Take the case of Pitney-Bowes. In 2001, with the aim of cutting health care costs, the office technology company sharply reduced employees' co-payments for diabetes and asthma drugs. Subsequently, the direct costs of treating patients with those diseases fell by more than 10 percent, presumably because the employees took the more affordable drugs regularly. A likely additional benefit: reduced absenteeism and presenteeism. Conversely, a study by researchers from Harvard Medical School and pharmacy benefits manager Medco Health Solutions, published last December in the New England Journal of Medicine, found that patients faced with a steep increase in their co-payments may stop taking necessary medications—a problem that, through increased absenteeism or presenteeism, could wipe out a company's savings in direct medical costs.

Hints such as these about the potential cost-effectiveness of investments in employee health are driving further research. The two forthcoming studies of companies in the Midwest and the Southeast, each involving several dozen organizations, will try to identify economic moves companies might make to stem health-related productivity losses. Another study, funded by the National Institute of Mental Health and involving 100,000 workers at a number of companies, including American Airlines and Northeast Utilities, is looking at whether depression-related presenteeism can be reduced cost-effectively through screening and outreach programs, access to inexpensive medication, and individual case management.

The poster child for a positive return on such investments is the flu shot. Numerous studies have shown that the cost of offering free shots is far outweighed by the savings realized through reductions in both absenteeism and presenteeism. There is also strong evidence that well-designed employee assistance programs (which offer counseling services for employees and their families), health risk assessments (which gather information from workers on conditions, such as high blood pressure, that may cause future health problems), and wellness programs (which promote healthy practices such as exercising and following a nutritious diet) more than pay for themselves by lowering companies' direct and indirect medical costs.

At the heart of programs like these is the belief that healthy employees are an asset meriting investment—that you may see a greater improvement in efficiency if you treat workers' asthma than if you install a new phone system.

Excerpted with permission from "Presenteeism: At Work—But Out of It," Harvard Business Review, Vol. 82, No. 10, October 2004.

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Paul Hemp is a senior editor at the Harvard Business Review.

A Presenteeism Report Card

Lockheed Martin commissioned a pilot study in 2002 to assess the impact of twenty-eight medical conditions—some serious, some relatively benign—on workers' productivity. Researchers from Tufts-New England Medical Center in Boston found that even employees with less severe conditions had impaired on-the-job performance, or presenteeism. The table below lists several of the ailments studied; for each one, it includes estimates of prevalence, productivity loss, and annual cost to the company in lost productivity (this figure was based on the average Lockheed salary, roughly $45,000). Together, the twenty-eight conditions set the company back approximately $34 million a year.



Average productivity loss

Aggregate annual loss


12.0 %

4.9 %






Chronic lower-back pain (without leg pain)




Allergies or sinus trouble








GERD (acid reflux disease)




Dermatitis or other skin condition




Flu in the past two weeks








Source: Debra Lerner, William H. Rogers, and Hong Chang, at Tufts-New England Medical Center


2. See Wayne N. Burton, Alan Morrison, and Albert I. Wertheimer, "Pharmaceuticals and Worker Productivity Loss: A Critical Review of the Literature," Journal of Occupational and Environmental Medicine, June 2003.