(This vignette is an edited version of Karen Belkic and Peter Schnall’s article, On a San Francisco public transport line: Burden and consequences upon the human operator, Job Stress Network, 2000)
Operating a motor vehicle in a city is an activity familiar to most people. Yet the toll this activity takes on the human nervous system and target organs is under-appreciated. Imagine transporting thousands of people each day via narrow, hilly streets, facing innumerable obstacles under inexorable pressure to keep to a strict schedule, knowing that the slightest accident could result in injury to a passenger and jeopardize your job. And imagine that this activity consumed 8 or more hours a day, 5 or more days in a row. These and many other stressors comprise the everyday experience of the San Francisco urban transport operators, who encounter problems specific to their city, but who also in many ways, exemplify the difficulties faced by transit operators in most metropolitan centers.
The traveling public never witnesses a transit operator’s daily “start-up” procedure. Before beginning on the transit line, the operator must sign in and meet a dispatcher to receive the schedule, learn about any detours, etc. The dispatcher could be a source of support and encouragement. However, given the pressures of urban transport life faced by both dispatchers and operators, interaction with the dispatcher can be an additional stressor even before the day’s driving work begins. The operator then locates the assigned vehicle and has a mere 10 minutes to make a detailed safety check on the vehicle, set up its destination sign, adjust the seat and mirrors, and program the radio and fare boxes. A working radio is the operator’s “lifeline” – the communication system without which s/he cannot proceed. Incessant pressure to turn to the right side means that drivers’ seats often are completely worn out. In fact, bus drivers’ equipment is often old and worn. If any of these elements is not functioning properly, the allotted time becomes inadequate. If another bus is blocking the way out, a further delay and increased stress may result. The first few minutes of operating the vehicle are the most precarious with regard to accident risk.
Drivers are responsible for the safety of their passengers and vehicle. Mass transit vehicles often handle poorly, brake slowly and, in the case of electric trolley cars, must be stopped only in locations where they will not lose contact with the overhead grid. Traffic is often heavy. Pedestrians have the right of way and may demand it under dangerous circumstances. There are often too many passengers and not enough buses. Drivers are frequently behind schedule and trying to catch up, and as a consequence, may not be able to take the prescribed breaks. This may result in excessive fatigue, leading to frayed nerves, poorer driving and more conflict with passengers.
San Francisco’s hills present a major difficulty for bus drivers, affecting visibility and creating difficulty in maneuvering. Significant muscle strength is required to hold the brakes on the downhill. San Francisco also has many narrow streets, not designed for heavy traffic. A double-parked car on a narrow street can be sufficient to cause a major traffic blockage. Having to make sharp turns with a large vehicle on these streets is challenging, slowing the driver down as well as presenting an accident risk.
A number of San Francisco’s mass transit lines are equipped with trolley buses, connected to a power line by a pole, which can be displaced. When this happens along a narrow street traffic can become totally blocked. In the midst of the jam, the operator must get out of the vehicle and try to put the connecting pole back in place using a tension cable, a procedure requiring considerable physical strength. When the driver tries to put the pole back in place quickly while standing in the midst of congested traffic, arm and shoulder injuries can easily occur.
The magnificent panoramas that dominate San Francisco’s landscape mean that transit operators must shut off part of their visual attention system in order to continuously monitor the traffic situation. A natural way for drivers to recover at the end of the line would be to step out of their vehicle and have a chance to enjoy San Francisco’s unique panoramas. This kind of pause accompanied by a brisk walk could be incorporated into “recovery time”, or guaranteed rest breaks, coherent with what is known about healthy work practices. Indeed, it has been recommended that city bus drivers have at least a 20-minute break after each 2 hours behind the wheel.[i] Yet, transit operators often are unable to take even the short break that is scheduled at the end of each driving tour. When the driver reaches the end of the tour behind schedule, back-up is seldom, if ever, available. Knowing that passengers for the next tour are waiting, getting more impatient by the moment, most drivers opt to skip or at least shorten their break, an attempt to ameliorate passengers’ impatience, and to try to get back on schedule. This means that the driver sacrifices his/her own comfort, and in the long run health and well being to compensate for the city’s traffic congestion and the lack of adequate numbers of drivers and vehicles.
…and not going
Minimum conditions for hygiene are frequently lacking at rest sites. Restrooms for drivers, often ill-maintained, are mainly found along the route itself, requiring an unscheduled stop. In addition to the discomfort and inconvenience of this situation, there are potential health consequences for the drivers, such as risk of urinary tract infection, from insufficient toilet breaks, and dehydration from not drinking enough fluid because of the insufficient toilet breaks.
San Franciscans rely on public transportation and expect punctuality. Passengers may enter the bus already upset by long waits and being late for their appointments, etc. A transit operator can be cited if a passenger complains. The city’s urban transit operators have received bad press, not unusual for transit operators around the world. The hard work of these drivers rarely, if ever, makes the front page.
Simply getting people on and off at each stop is a time-consuming challenge for drivers. Passengers often fail to realize how important it is for them to move to the rear to keep the driver’s view clear. No one wants to be left behind because the bus is over-crowded, and invariably it is the driver who bears the brunt of passengers’ anger when this situation arises. Asking people to move back in the bus and explaining why no more passengers can come on costs the driver time and energy. As well, unruly passengers may congregate in the back of the vehicle. Thus, while following the traffic situation the driver must also keep an eye on behavior at the rear of the bus, a difficult task that can compromise passenger safety.
Inexorable time pressure is a fact of daily life for the urban transport operator, whose life becomes governed by the clock and is measured in time units of minutes. Waking for morning rush hour passengers often means rising at very early hours – sometimes 2 or 3 AM. Scrupulously punctual drivers, fearful of not hearing the alarm, report sleeping lightly or not at all in anticipation of this early, strictly defined wakening time. Running late – often not the fault of the driver – will compromise or eliminate the already short rest break usually scheduled at the end of the line. If the schedule is more severely compromised, punitive measures may be taken. The driver is continuously pressing to catch-up with the schedule.
Research shows that objective barriers consume at least 30 extra minutes for nearly half of 4-hour work segments, [ii] and that there is a fundamental conflict faced by urban mass transit operators: keeping on schedule versus providing for the immediate, specific needs of the public. This means not only answering questions, but also many other services, most notably, taking the extra time to accommodate the disabled and elderly.[iii]
In typical urban settings passengers also are exposed to numerous difficulties in using public transportation, starting with frequent long waits for tardy vehicles, often in inclement weather. They enter the bus late for their destination, tired and perhaps ill or infirm, frequently to find standing room only. Buses are unsteady, stop suddenly and lurch, making it difficult to remain stable on one’s feet. Vehicles may be cold or overheated, and one may be pressed tightly against others. A single rowdy, or violent passenger can be frightening; the elderly and the otherwise frail are particularly vulnerable.
Violence on the job
Varying in degree from one urban center to another, the threat of violence is a common and major stressor for transit operators, who are vulnerable to violent attack at any moment. Drivers being robbed at knife or gunpoint are not uncommon events. The social problems of urban society are often manifested in hostile acts directed against the transit operator; carrying cash and transfers increases their vulnerability. Besides physical danger, frustrated persons often verbally vent their rage at the transport operator. They may complain about the bad conditions in the vehicle itself, about which the driver is well aware but which s/he cannot control. The urban mass transit operator has to be a pseudo psychologist to anticipate and handle all kinds of people and their troubles, and to devise coping strategies to minimize disruption from these complaints.
However, interaction with the public is also a source of satisfaction and gratification, explaining why suggestions for constructing compartments to separate the operator from the public in numerous settings, including San Francisco, have met with nearly universal opposition. Drivers expressed that this would create a sense of isolation and alienation. Suggestions for requiring 2 transport operators on high-risk transport lines have been resisted by the companies, based on cost.
Vigilance and avoiding accidents is doubly burdensome for professional drivers. Even under ideal circumstances, professional driving requires a high degree of vigilance to avoid accidents. The driver must continuously follow a barrage of incoming signals, to which s/he must be prepared to rapidly respond. A momentary lapse of attention, or even a seemingly slight error or delayed response could have potentially disastrous consequences. For the urban transit operator this burden is much greater than for an amateur driver. For example, s/he must watch right-left-right-left before making any move, whereas the amateur driver usually makes just three visual direction shifts. An eye must be kept open for oncoming and exiting passengers and anyone at the side of the curb. There is a need to watch on the right far more than for amateur drivers. This can be one of the factors contributing to the high rate of neck and other spinal pain among bus drivers, which is associated with number of years in the occupation. Furthermore, in situations where an amateur driver would brake (or quickly change lanes or make another rapid maneuver), the urban mass transit operator must think about the fact that people are standing, including frail passengers and people unsteady on their feet, and must try to maneuver accordingly. These dilemmas are not always resolvable. If someone falls inside the vehicle, the transit operator is held liable. It should be noted that anyone could stagger onto the bus, unstable on his feet, etc. requiring yet additional vigilance for the transit operator. The biggest worry is always about an accident, whether big or small. Even a seemingly trivial accident may result in injuries to passengers.
One may think that with experience and time on the job, a city transit operator will adapt to these conditions, difficult as they may be. Indeed, the acquired coping skills and knowledge of a seasoned professional driver are irreplaceably valuable assets, without which it would be practically impossible to continue in this line of work. There is a high turnover rate among urban mass transit operators. Those remaining on the job for 10 or more years are a highly select group.
Your health or your job
However, a heavy price is paid for years on the job. The very skills that get the driver through a working day serve to quietly displace the burden onto his/her target organs: the heart, blood vessels, gastrointestinal tract, and musculoskeletal system. Laboratory simulation and field studies demonstrate that the experienced drivers who cope silently and who appear to handle with ease the continuous barrage of potential dangers and who toughly deny how difficult this work is, are those who show the most dramatic blood pressure and electrocardiographic responses to the threatening stimuli of the traffic environment. Research shows that professional drivers are second to none as an occupational group at risk for hypertension and ischemic heart disease, and that these diseases occur at a relatively young age. Studies of heart attack patients under the age of 40 report a marked overrepresentation of professional drivers – up to 40% in some studies. Studies from Europe, the U.S., Latin America, East Asia and India show a high risk among this occupational group for cardiovascular and cerebrovascular disease, musculoskeletal disorders and/or peptic ulcer disease. Many of these studies found a strong relation between number of years on the job and/or number of daily hours behind the wheel linked with illness.
The human toll from these diseases, coming at an early adult age, also translates into enormous economic costs: absenteeism, disability and early retirement. It is unusual for a mass transit operator to retire at term in any city. In the Netherlands, for example, 48 is the average age of retirement for city bus drivers and is usually disability-based, with only 12% working until the normal retirement age of 60.
Much can be done
Public transportation is under-funded. Everyone is being forced to make due with less, thus for both the driver and the passengers, a bus ride may be a difficult experience. Passengers and drivers may take out their frustration on each other, instead of directing these urgent concerns towards those who are in a position to implement the needed changes.
We have discussed only a few of the many stressful, noxious conditions in the urban transport operator’s work environment. Quantitative analysis shows that the total burden of occupational stressors faced by the city bus driver is over twice that of construction workers and other trades known to be quite tough. The scientific community has called for urgent interventions to reduce occupational stress among urban transport operators,[iv] and various strategies to prevent bus drivers’ stress have been published.[v] Experts in this area agree that limiting the number of hours behind the wheel, guaranteed rest breaks, and diminishing time pressure are essential minimal requirements for all urban transit operators. More attention to the special health needs of professional drivers, and primary prevention programs are also necessary.
Innovations to improve the bus drivers’ working conditions have been made in Sweden, focusing on the toughest bus route in Stockholm. Streets were widened on some parts of the route, a special bus lane was created for a large portion of the route, and a number of other changes were implemented. The changes have resulted in some improvements to blood pressure and other physiologic measures among a small group of drivers who were examined before and after the changes were made. San Francisco’s specific characteristics, such as its narrow, hilly streets, however, necessitate a different approach. One such innovation for improvement is the “Ambassador Program”, which is discussed at the end of this chapter. This program has provided hope for both operators and passengers, and once again highlights the benefits that can be achieved through study, reflection, and action designed jointly with workers, management and researchers.
[i] Kompier MA, Di Martino V. Review of bus drivers’ occupational stress and stress prevention. Stress Med 1995; 11: 253-262.
[ii] Greiner BA, Ragland DR, Krause N, Syme SL, Fisher JM. Objective measurement of occupational stress factors–An example with San Francisco urban transit operators. J Occup Health Psychol. 1997; 2: 325-342.
[iii] Gardell B, Aronsson G, Barklof K. The working environment for local public transport personnel. Stockholm: The Swedish Work Environment Fund, 1983.
[iv] Michaels, D., Zoloth, S.R. Mortality among urban bus drivers. Int J Epidemiol 1991; 20: 399-404.
[v] Kompier and DiMartino, ibid, Stress Med, 1995
About 4 million motor vehicle operators, including 0.7 million bus drivers are among the heaviest occupational groups in the United States. Little is known about occupational and behavioral risk factors for obesity among bus drivers, particularly minority (African-American and Hispanic) urban bus drivers. Also, few validated instruments are available for research on work and obesity among bus drivers. The ultimate goal of this study is to design and conduct effective and sustainable worksite obesity intervention studies that lower the risk for obesity and cardiovascular disease in urban bus drivers. The specific aims of this study, based on a participatory action research approach and with multiple research methods, are to a) continue to expand the ongoing collaboration between a multidisciplinary research team at the UC Irvine Center for Occupational and Environmental Health (UCI COEH), the Los Angeles County Metropolitan Transit Authority (LACMTA), the local union of the United Transportation Union (UTU), and the United Transportation Union – Metropolitan Transportation Authority Trust Fund (UTU-MTA Trust Fund) Wellness Program to form a Research Advisory Committee, b) to conduct six interviews, walk-throughs, and six focus groups (in total, up to 60 bus drivers) at LACMTA division offices or the LACMTA headquarters with bus drivers and other key informants in management, union, and the wellness program to identify and prioritize the specific working conditions and health-related behaviors associated with obesity among LACMTA bus drivers, and c) develop a bus driver work and health questionnaire based on existing surveys and an extensive literature review that will be culturally sensitive to the diversity of LACMTA bus drivers and will be further tested and used in future epidemiological observational and intervention studies. This study meets several research strategic goals of the National Occupational Research Agenda (NORA).
There are about 4 million motor vehicle operators, including 0.7 million bus drivers in the United States [1-2]. Obesity, an excessive accumulation of body fat, is a key health issue among bus drivers who have a high risk for cardiovascular disease (CVD) [3-4]. Bus drivers along with other motor vehicle operators were the first and second rank in prevalence of obesity among 41 male and female occupational groups in the United States . Bus drivers (n=4,772) in the Los Angeles County Metropolitan Transit Authority (LACMTA) also have a very high percentage (86%) of African American and Hispanic drivers, whose risk of obesity and cardiovascular mortality is high compared to other ethnic groups. Little is known about occupational and behavioral risk factors for obesity and CVD among bus drivers, especially minorities. In addition, few validated instruments are available for research on work and obesity among bus drivers. The ultimate goals of this pilot study are to improve the cardiovascular health of bus drivers at the LACMTA and to reduce health disparity among working populations with diverse ethnic backgrounds by designing and conducting effective worksite obesity intervention studies. The specific aims of our study, based on a participatory action research (PAR) approach and with multiple research methods, are to a) continue to expand the ongoing collaboration between UC Irvine researchers, the LACMTA and the local union of the United Transportation Union (UTU) to form a Research Advisory Committee, b) to conduct interviews, walk-throughs, and focus groups with bus drivers and other key informants in management, the union, and the wellness program to identify and prioritize the specific working conditions and health-related behaviors associated with obesity among LACMTA bus drivers, and c) develop a bus driver work and health questionnaire that will be used in future epidemiological and intervention studies and will be culturally sensitive to the diversity of LACMTA bus drivers.
Background and Significance:
Why We Need To Learn More About Occupational and Behavioral Risk Factors For Obesity In Urban Bus Drivers. Obesity is a serious public health issue in the general population and among workers in the United States (US) [1, 5, 6]. Obesity has been well documented as a key risk factor for a wide range of chronic diseases such as hypertension, coronary heart disease, osteoarthritis, dyslipidemia, Type II diabetes, some cancers as well as increased mortality [7, 8]. Despite the high obesity prevalence rate among bus drivers, there have been few observational or intervention studies on bus drivers and obesity. To the best of our knowledge, only one cross-sectional epidemiological study  specifically examined significant differences in some health-related behaviors between normal weight and obese bus drivers in the Metro Transit Council of Minneapolis, Minnesota. While the study identified some behavioral risk factors for obesity among the bus drivers (e.g., less moderate or vigorous level of physical activity, more time sitting, more time watching television, and more frequent intake of soft drinks), the study was very limited in identifying the occupational risk factors which can affect adiposity of bus drivers directly or indirectly via or in combination with health-related behaviors among bus drivers. Ignoring structural barriers to healthy behaviors likely results in, at best a moderate success of obesity prevention among working populations in the short term, and in the long term the success cannot be maintained [10, 11]. In addition, worksite interventions targeting physical activity and dietary behaviors with a work environment component, albeit still scarce, have been found to be more effective in reducing weight than those without a work environment component .
There is emerging evidence that several adverse psychosocial working conditions can increase the risk for obesity among working populations (for review, see [13-15]). This was the case in our recently completed NIOSH funded project (called hereafter the FORWARD study) on work and obesity with firefighters who worked for Orange County Fire Authority (OCFA). Bus drivers have similar adverse psychosocial working conditions to firefighters: e.g., shift work [split-shift, a work shift is divided into two time zones (morning and afternoon) with an in-between non-work time], long work hours (up to 15 hours per day in the LAC-MTA workers); prolonged sedentary work, time pressure, low decision authority, and poor social relationships with coworkers supervisors, and customers) [3-4]. Additional stressful working conditions of bus drivers (e.g., violence from passengers; threat-avoidance vigilance; traffic and road conditions; work and family conflict; mechanical problems with the buses; poor safety climate; and labor-management relationship) [3-4] may contribute to increasing the risk for obesity among bus drivers.
A few articles of interest:
Exploring Occupational and Behavioral Risk Factors for Obesity in Firefighters: A Theoretical Framework and Study Design
Exploring Occupational and Health Behavioral Causes of Fireﬁghter Obesity: A Qualitative Study