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Labor Pains

As American labor transitions from the assembly line to the office cubicle, fewer workers risk death in explosions or industrial accidents. But serious health risks still lurk in the swiftly changing 21st-century workplace.

By Mike Field

A long line of grim-faced men in work boots clutching lunch pails passes through a narrow gate in a chain-link fence. A whistle screams. Up ahead, the roar and clang of production pounds through the factory's streaked windows and dirty brick walls. Acrid smoke laces the air.

During much of the 20th century, this was just everyday work—hard, hot, noisy, utterly glamourless, sometimes dangerous and occasionally lethal. In earlier decades especially, fires, explosions and industrial accidents both large and small regularly injured and killed thousands of workers each year.

Today in America, jobs have migrated from the factory floor to the office cubicle, the fast-food restaurant and the family business. The hours are long, the pace is frantic, and the windows are hermetically sealed. While hardly rife with the lethal threats so common in past decades, the 21st-century American working environment is relentlessly stressful. And no one knows for sure exactly what health consequences arise from this new kind of workplace.

Nor is it easy to tell. Workers today change jobs frequently. Many find jobs with small businesses, privately held companies too tiny and with too few resources to rigorously observe worker health and safety practices. In this environment, work's effects on health are unlikely ever to come to light. Another complicating factor is that Americans are staying on the job longer—some well into their 70s—and living for decades beyond retirement.

"If you look for one big trend in occupational health, it is this transition from studying the effects of high-level toxin exposures to beginning to think about workplaces without traditional hazards," says Brian Schwartz, Environmental Health Sciences (EHS) professor and director of the Division of Occupational and Environmental Health. "The new concerns are mental health, stress, indoor air quality and other less overt dangers."

Schwartz is one of many Bloomberg School faculty researching ways to keep contemporary workers safe and healthy—in environments ranging from office buildings to chicken farms.

American Work Shifts

Half a century ago, the School's Anna Baetjer conducted groundbreaking research that linked workplace chromium exposure to lung cancer. Her work paved the way for a new era in occupational health and industrial hygiene at a time when most workers stayed at a job for many years—and not uncommonly, for all their lives. The work of Baetjer and her colleagues focused on keeping workers safe on the factory (or mill or processing) floor. A fairly constant workforce in stable industries made it relatively easy to associate certain workplace exposures—such as chromium dust—with subsequent health outcomes like cancer.

But that world changed. "We are no longer a manufacturing economy," notes Schwartz, MD, MS. "Only a small percentage of American workers are engaged in manufacturing, and the number continues to fall." Today, manufacturing jobs account for less than 15 percent of U.S. employment.

"Most workers today are in the service sector. There has been a dramatic decline of unions and organized workers, especially in the manufacturing sector, and a global trend to the free movement of capital, goods, information and services—but not people," says Schwartz. "In manufacturing there has been a rush to the bottom, looking for lower labor costs and less strict occupational and environmental laws in other countries."

In the United States, recent immigrants tend to stay "beneath the radar" of many occupational health protections because they often work in small or family-owned businesses. Jacqueline Agnew, EHS professor and director of the School's Education and Research Center in Occupational Health and Safety, cites one example: Vietnamese nail salon workers. "These are workers who typically spend 60-plus hours a week on the job," she says, "where they receive high exposures to methyl methacrylate used to create artificial nails. It has been linked to neurological symptoms, but we currently have no way of knowing how it may affect these workers." Recently, the National Alliance of Vietnamese Service Agencies teamed with Bloomberg School researchers to begin investigating how to design voluntary interventions that could help reduce chemical exposure levels and other work hazards among salon workers.

Agnew, PhD '85, MPH '78, and her team begin by asking both workers and owners (who often work side by side) to identify any health-related issues they are experiencing. In addition to chemical exposures, health concerns include musculoskeletal risks presented by the work's ergonomic demands. Agnew hopes the research, which is continuing, will lead to a healthier work environment.

One curious irony of the new economy is that even as traditional industries have decamped to foreign shores, other occupations previously performed by individual owner/operators are becoming increasingly industrialized. Take, for instance, raising food animals.

"People don't understand what has happened to animal farming in this country; it has really become an industrial process," says Ellen Silbergeld, EHS professor. "The farmers are now contractors to the corporations, and their job is to provide animals to the processing plants seven days a week, 24 hours a day. The farmers who actually raise the animals have very little control."

A prime example: Poultry farmers on the Chesapeake Bay's Eastern Shore. They operate on a contractual basis with the big poultry producers, agreeing to raise a certain number of chickens at a specified price within a set time. In these arrangements—which Silbergeld, PhD '72, describes as "basically a modern form of share-cropping"—the chicken producers provide the feed (which often includes antibiotics to speed growth). But the health consequences of this practice—both to consumers and to the farmers and workers who handle the antibiotic-impregnated feed and wastes from their animals—are largely unknown.

Among the potential health risks posed to poultry farmers and workers are drug-resistant infections bred through the indiscriminate use of antibiotics. Silbergeld's team is studying antiobiotic-resistant bacteria in farmers, farm workers and residents on the Eastern Shore to see if their levels are higher than in the general population. Silbergeld says the practice also accounts for high levels of antibiotic-resistant bacteria found on some consumer meat products. Earlier this year, Lance B. Price, MS, a doctoral student working with Silbergeld, compared store-bought chicken samples from large producers with samples from nonantibiotic using producers, and found significantly higher levels of drug-resistant bacteria on the products of big-name brands. The results were published this spring in Environmental Health Perspectives. "This is a double risk, first to the farmers and workers who handle the chickens, and then ultimately to all of us who eat them," says Silbergeld. "There are a lot of potential victims in this story."

Though their work is vastly different, the chicken farmers and Vietnamese nail salon workers do have one thing in common: They work for businesses whose small size and disparate locations make monitoring and surveillance especially difficult. The Occupational Safety and Health Administration was created with large pools of centrally located, long-term workers in mind.

"We have not, as a society, done well in figuring out how to monitor and ensure worker health and safety in small companies," says Clifford Mitchell, EHS associate professor and director of the School's Occupational Medicine Residency Program. "Occupational health resources tend to be concentrated in large companies, but increasingly you have all sorts of mom-and-pop operations working with all kinds of exotic materials." He worries that safety precautions against even known hazards can be easily ignored, either willfully to save money or out of simple ignorance. "There are a whole host of companies that we just don't know about—who they are, where they are, how bad things are. For all intents and purposes, they're invisible," says Mitchell, MD, MPH '91.

Stress Tests

The Japanese have a word for it: karoshi, meaning death from overwork. And in America, more employees than ever report being "stressed out."

But what exactly does being stressed out mean, and how do you measure it? And how do you show conclusively that workplace stress affects immediate or long-term employee health? Researchers around the world have found it extremely difficult to conclusively link pressures on the job with heart attacks, say, or strokes, in the same way that black lung disease can be associated with inhaling coal dust in a mining operation.

Agnew's research has focused on developing and validating specific measures of occupational stress among such different groups as garment workers and Army Reservists. Agnew believes that "stress management" is largely a misnomer. "What we need to be doing is finding ways to remove the stressors," she says. "If it was workplace exposure to a chemical, we wouldn't simply tell folks to hold their breath."

Strain caused by stress can take different forms. "In our study of garment workers, those with high demands, low control and low levels of social support had the highest risk of musculoskeletal disorders," Agnew says. "Assembly work using quotas, pay incentives and piece-rate systems pressures workers to work very quickly and causes stress. The way to counter that is to reduce long working hours, set a reasonable job pace, encourage work breaks and allow workers to have more say in how their job is designed."

Past research has shown that jobs without much worker input or control tend to be more frustrating and stressful for workers. "Mental health issues are a very important concern for employers, in terms of health care costs and indirect costs associated with absenteeism and decreased productivity at work," Schwartz says.

Another potential hazard for workers is "sick" office space. Today's employees complain about experiencing a bewildering array of illnesses and side effects, from respiratory impairment to migraine headaches and musculoskeletal injuries, all of which may—or may not—be caused by the work environment.

Says Mitchell, "Increasingly our focus is on indoor environments. Workers today inhabit a variety of boxes of different kinds: Some are well built, some are not. Some are adequately ventilated, some are not."

In the 1970s, windows that could be opened started to disappear from most commercial buildings. To prevent illness, the heating, ventilation and air- conditioning systems in buildings must be carefully maintained. Often, however, this doesn't happen, and the results can lead to everything from mold allergies to Legionnaire's disease. "Generally with indoor air exposures we're not talking about acute toxic exposures," Mitchell says, "but instead these steady, low-level exposures that, even if they are not life-threatening, can still be disabling."

Workers can experience increased incidence of asthma, allergies, sinusitis and other forms of respiratory illness from poorly designed or maintained air-handling systems. "These are not imagined diseases," says Mitchell, who notes that too often employers and building owners tend to discount worker complaints. "We need to respond to these as genuine health threats."

Working Over Time

"In the past, you retired at age 65 and lived to be about 70, and so at the end of your working career it was sort of 'good luck and good bye,'" says Pat Breysse, EHS professor. "But now if you are going to live to be 90, there are additional needs that must be met. As people live longer, the likelihood that workplace exposures will result in chronic diseases increases. If an exposure takes 30 or more years to develop into disease, oftentimes you won't see the effect of what happened in the workplace until after people have retired."

Breysse, PhD '85, MHS '80, should know. For more than a decade, he has led a health study of former workers from Los Alamos National Laboratory (LANL)—workers who conducted weapons research throughout the Cold War years that exposed them to a wide range of hazardous agents, including radiation, solvents, asbestos and beryllium. With colleagues Brian Schwartz, assistant professor Virginia Weaver and research associate Maureen Cadorette, Breysse is reviewing work histories and conducting medical examinations of these former lab workers. Over 2,300 examinations have been performed to date, screening for health effects such as cancer, chronic lung diseases and hearing loss from exposure to hazardous agents.

Former workers found to have potentially work-related diseases are referred to occupational medicine physicians or specialty clinics. They can also apply for additional follow-up care and compensation.

Breysse is encouraged by what this effort may represent for the future. "This is the first case I'm aware of where an employer has assumed responsibility for exposure-driven, follow-up medical care for workers after they have retired," says Breysse. "There is a real need to supply ongoing medical surveillance for many workers in retirement. I hope this is the wave of the future."

Occupational health specialists also foresee an increasing need to address health issues of older workers, especially those who opt to work past age 65. "Right now, the 55-plus age group as part of the labor force is growing four times faster than any other segment," says Gary Sorock, associate professor in Health Policy and Management. "People need to work longer, or want to keep working part-time after they've retired. We're talking about a lot more older people at work."

Older employees present entirely new kinds of health and safety challenges, especially in terms of injuries, which still account for the vast bulk of costs in terms of medical expenses and employee lost time. "If you look at worker's compensation events, you see that about 95 percent are injuries and the remaining 5 percent are related to disease and illness," says Sorock, PhD.

In one study, Sorock and colleagues looked at 9,000 women in different professions age 55 and older who suffered fractures from falls on the same floor level—the kind that might occur when someone simply trips or slips. (Falls on the same level are the second most costly source of disabling injuries, behind overexertion.) They found that these injuries were more common than generally recognized, and in this age group they have a much greater impact on employee performance. "Fractures at work are often overlooked," Sorock says, "but they can be very common following a fall, particularly among older women. Our research indicates that as people are working longer, these injuries have the potential of becoming serious disability issues for workers and employers both."

Sorock's study found that moderate physical activity and standing on the job (as opposed to sitting all the time) were associated with a reduced risk of fractures. As the workforce ages, employers should be emphasizing the prevention of injuries in older adults by rotating jobs, moving them from sitting to standing and including a moderate amount of physical activity, he says.

Though U.S., Japan and other post-industrial nations report that worker injuries and deaths have declined steadily since the 1970s as tougher safety codes have been introduced and many hazardous occupations have moved overseas, it's still difficult to know exactly how safe the workplace is today.

"It's hard to just look at statistics we now collect and know everything we'd like to about what is going on," says Paul Locke, JD, DrPH '98, MPH, an attorney, scientist and visiting scholar in EHS. "Is it due to the fact we're not collecting the type of data that we should? Should we be moving toward collecting more information on chronic disease and the deaths they cause? Are there different illnesses we're not even considering?

"There has been a change in the workplace from the assembly line to the cubicle, and we need to keep up with those changes."