“Cardiovascular disease (CVD), including heart disease and stroke, is the major cause of disease and death in the industrialized world and is projected to become the most common cause of death worldwide by the year 2020. CVD and hypertension (high blood pressure) appear to be epidemics of recent historical origin, developing along with industrialization and urbanization, and now increasing in the context of economic globalization. Modern medicine focuses on individual risk factors for hypertension and CVD, often ignoring the important role that social factors, such as social class, work organization, and work-related psychosocial stressors, play in the development of hypertension and CVD. Social factors need to be fully integrated into explanations of disease development.
Increased CVD risk has been associated with job characteristics such as long work hours, shift work, “job strain” (a combination of high psychological work demands and low job decision latitude, or job control), high job efforts combined with low job rewards, injustice, job insecurity, and work that involves maintaining a high level of vigilance in order to avoid disaster, such as loss of human life. Sources of stress on the job (job stressors), besides acting directly on the human nervous system, may increase the risk of hypertension and CVD through a variety of mechanisms, including inhibiting healthy behaviors such as smoking cessation and exercise, or by producing psychological distress, such as anxiety and depression. Public health strategies are needed to address the pandemic of CVD, including worksite surveil- lance, development of the field of occupational cardiology, integration of health promotion with occupational health approaches, and job redesign.
THE SOCIAL-HISTORICAL CONTEXT
CVD, including heart disease and stroke, is the major cause of disease and death in the industrialized world, and is projected to become the most common cause of death worldwide by 2020 [1, 2]. In 2003, CVD caused 29.2% of all global deaths and 80% of all CVD deaths worldwide took place in developing, low- and middle- income countries .
Modern medical science has identified a number of individual risk factors for CVD including cigarette smoking, total and low density lipoprotein cholesterol, hypertension, fibrinogen, overweight, diabetes, and sedentary behavior (lack of exercise) . However, essential hypertension, the leading cause of CVD world- wide , is considered by many to be an unexplained disease (hence the name “essential”). Essential hypertension, as well as smoking, sedentary behavior, and diabetes, have been linked to work stressors. Thus, much remains to be learned about the role of work in the development of CVD.
CVD and hypertension appear to be epidemics of recent historical origin [5, 6]. A major cross-cultural study found virtually no rise in blood pressure (BP) with age and no hypertension among hunter-gatherers, herders, or traditional family farmers . In contrast, men and women in urban industrial societies have steady rises of blood pressure (BP) with age and hypertension is common [5, 6] (see Figure 1). This study also found large and significant correlations between BP and involvement in a money economy even after controlling for salt consumption and, for men, after controlling for body mass index (a measure of body weight) .
CVD, as a major cause of death, also developed at the same time as industrialization and urbanization [2, 7, 8], raising the question, what is it about industrializa- tion and urbanization that leads to hypertension and CVD? Evidence suggests that one important factor is the transformation of working life during the last 100-200 years in developed countries, away from agricultural work and relatively autonomous craft-based work toward machine-based (including computer-based) labor, based on the principles of the assembly line [9, 10]. Key features of the assembly-line approach to job design, whether in factories or offices, are high workload demands combined with low employee control or autonomy (known as “job strain”) , and, during periods of economic growth, long work hours.”
Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.
1. World Health Organization, The Atlas of Heart Disease and Stroke, World Health Organization, Geneva, Switzerland, 2004.
2. Graziano, J., Global Burden of Cardiovascular Disease, in Heart Disease, Zipes, D., P. Libby, R. Bonow, and E. Braunwald (eds.), Elsevier, London, UK, pp. 1-19, 2004.
3. Kannel, W. B., The Framingham Experience, in Coronary Heart Disease Epidemi- ology, Marmot, M. and P. Elliott (eds.), Oxford University Press, Oxford, NY, pp. 67-82, 1992.102 / UNHEALTHY WORK
4. Lawes, C., S. Vander Hoorn, M. Law, P. Elliott, S. MacMahon, and A. Rodgers, Blood Pressure and the Burden of Coronary Heart Disease, in Coronary Heart Disease Epidemiology, Marmot, M. and P. Elliott (eds.), Oxford University Press, Oxford, NY, pp. 152-173, 2005.
5. Schnall, P. L. and R. Kern, Hypertension in American Society: An Introduction to Historical Materialist Epidemiology, in The Sociology of Health and Illness: Critical Perspectives, Conrad, P. and R. Kern (eds.), St. Martin’s Press, New York, pp. 97-122, 1981.
6. Waldron, I., M. Nowatarski, M. Freimer, J. P. Henry, N. Post, and C. Witten, Cross- Cultural Variation in Blood Pressure: A Qualitative Analysis of the Relationship of Blood Pressure to Cultural Characteristics, Salt Consumption and Body Weight, Social Science and Medicine, 16, pp. 419-430, 1982.
7. Mackinnin, A., The Origin of the Modern Epidemic of Coronary Artery Disease in England, Journal of the Royal College of General Practitioners, 37, pp. 174-176, 1987.
8. Faergeman, O., The Societal Context of Coronary Artery Disease, European Heart Journal, 7:Supplement A, pp. A5-A11, 2005.
9. Landsbergis, P., P. Schnall, K. Belkic, J. Schwartz, D. Baker, and T. Pickering, Working Conditions and Masked (Hidden) Hypertension: Insights into the Global Epidemic of Hypertension, Scandinavian Journal of Work Environment and Health, Suppl (6), pp. 41-51, 2008.
10. Schnall, P., K. Belkic, P. A. Landsbergis, and D. Baker, Why the Workplace and Cardiovascular Disease?, Occupational Medicine: State-of-the-Art Reviews, 15:1, pp. 1-5, 2000c.
11. Karasek,R.andT.Theorell,HealthyWork:Stress,Productivity,andtheReconstruction of Working Life, Basic Books, New York, 1990.
“Political, economic, and cultural forces play major roles in how the work-health relationship is conceptualized, studied, diagnosed, and treated. As many historians have carefully documented, social forces such as politics and economics have much to say about what we know and do not know in science , much as they clearly influence what impact particular scientific findings will have. Similarly, some historians, social scientists, and analysts of medicine have long challenged the idea that disease categories and etiology reflect objective, natural states free from social and cultural influence.
Sociologist Sylvia Tesh , for example, could have been thinking of contemporary approaches to work and health etiology and prevention in the United States and Scandinavian countries when she argued that embedded in approaches to illness prevention lie “hidden arguments” of a social, political, and economic nature. Which scientific knowledge and theories are used, which are ignored, are all affected by political struggles among diverse interests, which reflect different beliefs about the relative responsibilities of the individual or the group (collective, community) for people’s health.
Arriving at the answers to these many questions involves debates and disagreements over data, evaluations of cause and effect, and battles over regulation and prevention that reflect assumptions, interests, and power well beyond the specific topics discussed. Objective scientific data constitute only one part of the picture and rarely provide simple or unambiguous answers. Rather, science is also a collective, social process in which consensus and authority are required in order for something to be legitimately identified as a “work-related illness.” Political and economic forces fight to influence which scientific findings are produced and circulated, which diseases are recognized and officially designated as “work-related.” In many developed countries such as Scandinavia, Canada, Italy where political and economic systems are oriented to the good of the collective—exemplified by universal policies of national health insurance, guaranteed paid vacation time for all workers, minimum pensions for all—and where not coincidentally the labor movement remains powerful, data connecting specific working conditions to health are routinely collected and the study of work and health significantly developed. In striking contrast, no national databases assessing working conditions and health of the same person even exist in the United States , making the scientific documentation of connections between workplace characteristics and health effects extremely difficult. In the United States, businesses might be subject to increased regulatory monitoring and loss of profit and control in the workplace if more common health problems (such as hypertension, cardiovascular disease, and depression) are recognized and defined as by-products of demanding, low control, and insecure work. In the absence of a national health plan in the United States, health costs are borne by businesses through the provision of health insurance and Workers’ Compensation.
The tendency to ignore the potential impact of work on health is most strikingly demonstrated in the near complete absence of questions about work and working conditions in the routine medical history taken by physicians in the United States, whereas “job strain” is illegal in a number of European countries .
One of the main “languages” in the United States is individualism: we think, talk, act, evaluate, explain, and blame first and foremost in terms of the individual rather than a community or a social context. We think of disease and illness in terms of risk factors or health habits or lifestyle or genes of an individual; we think of prevention as directed toward changing the individual—for example, through stress management techniques, more exercise, or healthy eating habits—rather than toward the workplace, community, economic, or political systems. The individual is considered responsible not only for his or her health but also for his or her achievement or failure at work, under the assumption of equal opportunity and meritocracy, a philosophy of, “you get what you deserve (or earn)” . Those who fail, by being sick, unemployed, underemployed, or poor, are often considered second-class citizens.
The dominance of individualism shows up in our everyday and professional language in which social phenomena are often referred to in psychological and/or individual terms. For example, work stress researcher Cary L. Cooper writes about, “The new psychological contract and associated stressors,” while asking: “How can organizations continue to demand more and more of their employees, including loyalty, while providing less and less job security and support? Is the psychological contract between employer and employee worth the metaphorical paper it is written on?” [27, p. 1].
Disease risk factors, such as smoking, drinking, and exercise behaviors, are approached as if they were entirely individual when in fact they are strongly affected by social factors, including work stress and social class, in their genesis and reinforcement. Cigarette smoking, as an example, arose as a common behavior in the early 20th century with the mass production of cigarettes and their widespread dissemination and use among troops during World War I to cope with combat stress. Weight is affected by work that requires less physical labor, and by work stress, which can exhaust people and limit their ability to exercise—factors not entirely within the control of individuals. Similarly, the experience of stress itself is often approached as a matter of individual will, as many stress management programs teach that “it’s up to you whether stress affects your health or not.” This book will show why this standard stress management advice is only one side of the story; even if we put them out of our minds and “get used to them,” chronic, everyday stressors in our work environment can still affect our health .
Final obstacles to greater recognition of social causes of illness lie in dominant approaches to knowledge in science in the United States. For example, social environmental conditions, such as social climate or a sense of powerlessness or job insecurity, which many people suspect affects their health, are readily dismissed as scientifically intangible and non-measurable, and thus receive little explanatory and preventive attention. Similarly, the fact of individual variation in response to environmental stressors is also used as support for individualist approaches. If response is varied, if not all people get equally stressed from the same situation, so the argument goes, the prime mover must be individual, not environmental. This approach to environmental toxins, including cigarettes, often reflects an ideology of survival of the fittest; rather than setting the bar to the threshold that protects the weakest so that everyone will be protected, the weakest individuals are “eliminated.”
Finally, most chronic illnesses have no one single cause, but rather result from multiple influences, one of which may be work. Working conditions can cause, contribute to, accelerate, or trigger symptoms of ill health. Requiring evidence that work is the only cause of an illness raises the threshold criteria for labeling some- thing work-related so high it discourages official recognition and prevention of the contribution of many working conditions to ill health and injury.”
Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.
Featured in the Journal of Occupational Health Psychology
LANDSBERGIS, CAHILL & SCHNALL
1999 Vol 1, No. 2, 108-130