Introduction to Consequences

“That ill health is a consequence of the way work is organized has generated a sizeable scientific research literature since the 1970s. Researchers in the field of occupational health and social epidemiology have developed models of psychosocial stressors that measure the complex ways in which the organization of work impacts the health of working populations. The building of a scientific knowledge base around occupational stress highlights the ways in which the “social,” particularly work organization, is related to the prevalence of both physical health problems in working populations (including cardiovascular disease and hypertension) and mental health problems (including psychological distress, anxiety, burnout, and depression). The key measures of work organization related to health include job characteristics such as job strain (the combination of high psychological demands and low decision latitude or control), social support, and effort-reward imbalance; as well as work hours, shift work, and the influence of downsizing, outsourcing, and flexible labor patterns.”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

Introduction to Cures

“This section describes some of the more innovative stratagems taking place in American society and elsewhere related to the protection of workers’ health. Revealed repeatedly are successful approaches to changing and improving work organization in order to diminish or eliminate threats to workers’ health. They employ two common elements: they draw on the body of scientific knowledge and rely on principles of collectivity. Underlying these elements is the notion of “balance of power” between workers and managers. It is clear that maintaining an understanding of what is demonstrated in the scientific literature, or at least liaising with people who are abreast of the body of knowledge, is important in achieving positive change. With these powerful tools in hand, numerous successful work organization change interventions have been achieved, using varied approaches. Innovative stratagems tailor the approach used to the nature of the workforce, the workplace, the type of work performed, and the type of labor- management relations and agreements that may exist.

Successful change initiatives described in this section have drawn on the strength and power that exist in collective bargaining agreements, labor-management partnerships, and from participatory action research. What is perhaps the most important message emerging is that strong collective voice is the singularly most important element found among all of the various interventions described. To date, few work organization change initiatives have succeeded in the absence of strong collective voice. Strong laws and regulations are also essential and much needed, but also need to be respected and enforced. During the last 25 years, the United States has witnessed a diminished lack of commitment to existing laws and regulations. Shown throughout this section, laws and regulations alone are not enough to protect workers’ health; other mechanisms are needed to ensure the implementation of statutory laws and regulations.”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.


“In the United States, burnout is not considered a clinical disorder. It is a syn- drome fundamentally linked to the workplace and, in the popular culture, to parenting and athletic performance. There is a lack of U.S. national data on burnout, but some studies of single occupations show that the prevalence of burnout in the work context is particularly high within human service occupations. Figures range from 9% among nurses [14] to as high as 45% among medical students [15]. Burnout is the result of prolonged exposure to chronic job stressors [16]. Christina Maslach developed an instrument to measure burnout which consists of three parts: emotional exhaustion, depersonalization or cynicism, and lack of professional efficacy or personal accomplishment [17]. Emotional exhaustion is considered to be the main component of the syndrome, referring to a feeling of depleted energy or emotional resources [16]. Depersonalization or cynicism refers to negative feelings and distancing from others at work and is the “interpersonal” component of the syndrome. Reduced personal accomplishment is a lowered sense of productivity and self-efficacy and represents the “self-evaluation” aspect of burnout.

Anxiety, burnout, and depression can all be present in the same individuals. Mechanisms explaining the relationship between these outcomes and work stress are not well understood [18] and, while undoubtedly related to each other, they may have different physiological effects:

“During its early stages, burnout may occur concomitantly with a high level of anxiety because of the active coping behaviors that usually entail a high level of arousal. When and if these coping behaviors prove ineffective, the individual may give up and engage in emotional detachment and defensive behaviors that may lead to depressive symptoms [19, p. 356].

Four cross-sectional studies have investigated the job demand and control model in relationship to burnout [44, 50]. Three of these four studies showed that demands and low control were associated with burnout. The non-supportive fourth study was of construction workers where burnout is not found to be as prevalent as in human service work. One study also investigated the role of social support among female social workers and found that those workers with high demands, low control, and low support were at greater risk of burnout [44].”

Burnout is considered more closely related to chronic stress at work while depression is considered to be more pervasive and caused by a multiplicity of factors from family/genetic history, personality, and past and present exposure to stressful life events [23, 24], as well as chronic work stressors. A recent study demonstrated a strong association between burnout and depression, where those with burnout were eight times more likely to also suffer from depressive symptoms and five times more likely to experience depression [25]. 

Burnout might be a pathway through which those with highly demanding jobs and with little control over the work environment develop depression. A recent study of more than 3,000 Finnish employees looked at the association between job strain, burnout, and depression [25]. They found that those with high job strain were 7.4 times more likely than those with low job strain to have burnout and that those with job strain had a 3.8 times higher risk for depressive symptoms. However, they also found that the increased risk for depressive symptoms and for depression as a disorder due to high job strain was reduced by 69% after adjusting for burnout. These findings suggest there may be multiple pathways leading to work-related depression (see Figure 3). However, because it was a cross-sectional study, alternate explanations of the results are possible; for example, there may be individuals in the study whose depression started before they were exposed to job strain and thus was caused by other risk factors.”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.


14. Melchior, M., H. Philipsen, H. Abu-Saad, R. Halfens, A. Van Der Berg, and P. Gassman, The Effectiveness of Primary Nursing on Burnout among Psychiatric Nurses in Long-Stay Settings, Journal of Advances in Nursing, 24, pp. 694-702, 1996.

15. Guthrie, E., D. Black, H. Bagalkote, C. Shaw, M. Campbell, and F. Creed, Psychological Stress and Burnout in Medical Students: A Five-Year Prospective Longitudinal Study, Journal of the Royal Society of Medicine, 91, pp. 237-243, 1998.

16. Melamed, S., A. Shirom, S. Toker, S. Berliner, and I. Shapira, Burnout and Risk of Cardiovascular Disease: Evidence, Possible Casual Paths, and Promising Research Directions, Psychological Bulletin, 132:3, pp. 327-353, 2006.

17. Maslach, C., S. E. Jackson, and M. P. Leiter, Maslach Burnout Inventory Manual,Consulting Psychologist Press, Palo Alto, CA, pp. 19-26, 1996.

18. Glass, D. C. and J. D. McKnight, Perceived Control, Depressive Symptomatology, and Professional Burnout: A Review of the Evidence, Psychology and Health, 11, pp. 23-48, 1996.

Ellen Rosskam Book Publications


E. Rosskam, and I. Kickbusch (eds.), Negotiating and navigating global health: Case studies in global health diplomacy, World Scientific, Imperial College, London. 2012. Hard cover and paperback.

D. Hill and E. Rosskam (eds.), The Developing world and state education: Neoliberal depredation and egalitarian alternatives, Routledge, New York, 2009. Paperback 2011.

P. Schnall, M. Dobson, E. Rosskam, (eds.), Unhealthy Work: Causes, consequences, cures, Baywood, New York, 2009. Voted “Best Labor Book Internationally of 2009.” (Also in Spanish, Mandarin, and Korean)

E. RosskamExcess BaggageLeveling the load and changing the workplace, Baywood, New York, 2007.

E. Rosskam (ed.), Winners or losers? Liberalizing public services, International Labor Office, Geneva, 2006.

C. Afford (E. Rosskam and A. Leather, eds.), Corrosive Reform: Failing health systems in Eastern Europe, International Labor Office, Geneva, 2003. Also in Russian.

Training Manuals

M. Keith, J.Brophy, P. Kirby, E. RosskamBarefoot Research: A Workers’ manual for organising on work security, International Labor Office, Geneva, 2002. Also in French, Hungarian, Turkish, Mandarin, Cantonese, Visnayan/Cebuano, Italian, and Spanish.

E. RosskamWomen moving mountains: Women workers in occupational safety and health, ILO Gender Training Kit, International Labor Office, Geneva, 2000.

E. Rosskam (ed.), Ergonomic checkpoints: Practical and easy-to-implement solutions for improving safety, health and working conditions, by Kogi, K., Kuorinka, I., et al., International Labor Office, Geneva, 1996 (second edition printed 2011). Also in Arabic, Bahasa Malaysia, Mandarin Chinese, Estonian, Farsi, Japanese, Korean, Polish, Portuguese, Spanish, French, Thai, Turkish, Vietnamese, Russian, Bahasa Indonesian.

E. RosskamYour health and safety at work: A collection of modules, International Labor Office, Geneva, 1996, CD ROM version: 1999. Individual booklets include: AIDS & the Workplace; Male/Female Reproductive Health Hazards in the Workplace; Health and Safety for Women/ Children; Using Health & Safety Committees at Work; Ergonomics; Chemicals in the Workplace; Controlling Hazards; Noise at Work; Legislation/Enforcement; Your Body at Work; Introduction to Occupational Health & Safety; Instructor’s Guide to the Modules. Also in French and Spanish, Arabic, Farsi, Hindi.

M. Brown, R.Baker, E. Rosskam, (eds), The VDT trainer’s kit: A Complete course on computer terminal health and safety, Labor Occupational Safety and Health Program, University of California, Los Angeles, and the Labor Occupational Health Program, University of California, Berkeley, 1991.

CWA Studies

The CSE’s research efforts are supported entirely by funds raised by contributions to the CSE or through contracts to evaluate worker health. The Center has developed and conducted occupational health projects with the support of 5 different unions and associated management groups over the last decade: HERE; UAW; CWA; IAFF; Orange County Fire Authority (Management).

The CSE recently finished a study conducted in November 2009 with Communications Workers of America (CWA) members employed as line-workers/technicians by Verizon in Southern California. Marnie Dobson (CSE Associate Director) prepared and presented a report to Verizon management and CWA representatives during a collective bargaining session in Southern Californian March 2010 and are in the mist of preparing a new proposal outlining a study to be conducted in collaboration with CWA and AT&T to further study line and call-center workers in Northern California. 

In 2011 the CSE submitted a proposal to Communications Workers of America (CWA) for a cross-sectional survey of AT&T technicians in California. We estimate the survey should be completed by approximately 600-800 technicians at 16-20 randomly selected worksites. This will give us sufficient statistical power to find credible associations between workplace stressors and self-reported health outcomes such as hypertension, cholesterol, obesity, burnout and psychological distress. We also recommend a random sample of N=200, among the participants of the survey population to collect physiological measurements such as work-site blood pressures, and height and weight. These “hard” outcomes are well established risk factors for CVD and are associated with work-related stressors and will add credibility to the study.

Our approach in previous research with CWA has included close consultation with CWA representatives and technicians and we strongly urge that this be repeated in a California study. Participatory Action Research (PAR) is an approach to conducting research which involves fostering a partnership between researchers and working people whereby the interests and knowledge of working people inform the research questions and process. PAR de-centers the research process to involve and empower those being studied to prioritize their concerns, gain knowledge about research processes from the academic researchers, foster successful participation among colleagues, and help interpret findings and develop recommendations for workplace change.

Social Support

Social support refers to the various types of support that people receive from others and is usually separated into two distinct categories: emotional and instrumental support. Emotional support is characterized by things that people do for each other that makes them feel cared for and supports feelings of esteem and worthiness. Instrumental support refers to the various types of tangible help that others may provide (i.e. financial support, child-care, etc). 

There does not, at this time, seem to be a “gold-standard” for social support scales as there are a variety of instruments currently used which have yielded scores successfully related to various health outcomes. Instruments range from single items used to assess whether or not major types of support are available to more extensive instruments including multiple items asking about various types of emotional support and various types of instrumental/informational support.

Choice of the appropriate measure(s) for use in research projects will likely be driven by such factors as: a) available time (some measures require considerably more time than others) and, b) whether assessments for different types of relationships are hypothesized to be important.


Summary prepared by Teresa Seeman in collaboration with the Psychosocial Working Group. Last revised April 2008.


Below: Multidimensional Scale of Perceived Social Support (Zimet, Dahlem, Zimet & Farley, 1988) 

Instructions:  We are interested in how you feel about the following statements.  Read each statement carefully.   Indicate how you feel about each statement. 


   Circle the “1” if you Very Strongly Disagree

   Circle the “2” if you Strongly Disagree

   Circle the “3” if you Mildly Disagree 

   Circle the “4” if you are Neutral

   Circle the “5” if you Mildly Agree

   Circle the “6” if you Strongly Agree

   Circle the “7” if you Very Strongly Agree


 1.  There is a special person who is around when I am in need. 

 2.  There is a special person with whom I can share my joys and sorrows.  

 3.  My family really tries to help me.  

 4.  I get the emotional help and support I need from my family. 

 5.   I have a special person who is a real source of comfort to me. 

 6.   My friends really try to help me. 

 7.  I can count on my friends when things go wrong

 8.  I can talk about my problems with my family. 

 9.  I have friends with whom I can share my joys and sorrows. 

10.  There is a special person in my life who cares about my feelings. 

11.  My family is willing to help me make decisions. 

12.  I can talk about my problems with my friends. 


In the classic Whitehall Study, an epidemiological study that followed middle-aged British civil servants over several years, researchers found that high job demands and effort-reward imbalance as well as low social support at work and low decision authority (e.g., job control) were associated with increased risk of psychiatric morbidity (including depression), even after controlling for psychiatric disorder at baseline, and adjusting for mood and “negative affectivity” [45]. 

While job demands and social support at the first stage of the study had a consistent impact on mental health at the next two time points (Phases 2 and 3), decision-making authority or control had less of an impact on psychiatric disorder at the last stage of the study than during the middle follow-up stage. The researchers suggest it might be because control at work has a more immediate effect on future mental health than other job characteristics [45, p. 306].  

Four cross-sectional studies have investigated the job demand and control model in relationship to burnout [44, 50]. Three of these four studies showed that demands and low control were associated with burnout. The non-supportive fourth study was of construction workers where burnout is not found to be as prevalent as in human service work. One study also investigated the role of social support among female social workers and found that those workers with high demands, low control, and low support were at greater risk of burnout [44].

Taken, in part, from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.




Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

C Muntaner, J Benach, W C Hadden, D Gimeno and F G Benavides A glossary for the social epidemiology of work organisation: part 2 Terms from the sociology of work and organizations

Hochschild AR. The managed heart. Berkeley: University of California Press, 1983.

Belkic, K., P. A. Landsbergis, P. Schnall, et al., Psychosocial Factors: Review of the Empirical Data among Men, in The Workplace and Cardiovascular Disease Occu- pational Medicine: State of the Art Reviews, Schnall, P., K. Belkic, P. A. Landsbergis, and D. Baker (eds.), Hanley and Belfus, Philadelphia, PA, pp. 24-46, 2000.

Belkic, K., P. Landsbergis, P. Schnall, and D. Baker, Is Job Strain a Major Source of Cardiovascular Disease Risk?, Scandinavian Journal of Work Environment and Health, 30:2, pp. 85-128, 2004.

Siegrist, J., R. Peter, A. Junge, P. Cremer, and D. Seidel, Low Status Control, High Effort at Work and Ischemic Heart Disease: Prospective Evidence from Blue Collar Men, Social Science and Medicine, 31, pp. 1127-1134, 1990.

Kivimaki, M., M. Virtanen, M. Elovainio, A. Kouvonen, A. Vaananen, and J. Vahtera, Work Stress in the Etiology of Coronary Heart Disease—A Meta-Analysis, Scandina- vian Journal of Work Environment and Health, 32:6(Special Issue), pp. 431-442, 2006.

Vahtera, J., M. Kivimaki, J. Pentti, et al., Organisational Downsizing, Sickness Absence, and Mortality: 10-Town Prospective Cohort Study, British Medical Journal, 328:7439, p. 555, 2004.

Kivimaki, M., J. Ferrie, E. Brunner, et al., Justice at Work and Reduced Risk of Coronary Heart Disease among Employees: The Whitehall II Study, Archives of Internal Medicine, 165, pp. 2245-2251, 2005.

Elovainio, M., P. Leino-Arjas, J. Vahtera, and M. Kivimaki, Justice at Work and Cardiovascular Mortality: A Prospective Cohort Study, Journal of Psychosomatic Research, 61 pp. 271-274, 2006.

Menotti, A. and F. Seccareccia, Physical Activity at Work and Job Responsibility as Risk Factors for Fatal Coronary Heart Disease and Other Causes of Death, Journal of Epidemiology and Community Health, 39, pp. 325-329, 1985.

Murphy, L. R., Job Dimensions Associated with Severe Disability Due to Cardio- vascular Disease, Journal of Clinical Epidemiology, 44:2, pp. 155-166, 1991.

Suurnakki, T., J. Ilmarinen, G. Wagar, E. Jarvinen, and K. Landau, Municipal Employees’ Cardiovascular Diseases and Occupational Stress Factors in Finland, Inter- national Archives of Occupational and Environmental Health, 59:2, pp. 107-114, 1987.

Belkic, K., R. Emdad, and T. Theorell, Occupational Profile and Cardiac Risk: Pos- sible Mechanisms and Implications for Professional Drivers, International Journal of Occupational Medicine and Environmental Health, 11, pp. 37-57, 1998.

Tuchsen, F., High-Risk Occupations for Cardiovascular Disease, in The Workplace and Cardiovascular Disease, Schnall, P., K. Belkic, P. Landsbergis, and D. Baker (eds.), Hanley & Belfus, Philadelphia, PA, pp. 57-60, 2000.

Greiner, B., N. Krause, D. Ragland, and J. Fisher, Occupational Stressors and Hyper- tension: A Multi-Method Study Using Observer-Based Job Analysis and Self-Reports in Urban Transit Operators, Social Science and Medicine, 59, pp. 1081-1094, 2004.

71. Kivimaki, M., J. Ferrie, E. Brunner, et al., Justice at Work and Reduced Risk of Coronary Heart Disease among Employees: The Whitehall II Study, Archives of Internal Medicine, 165, pp. 2245-2251, 2005.

72. Elovainio, M., P. Leino-Arjas, J. Vahtera, and M. Kivimaki, Justice at Work and Cardiovascular Mortality: A Prospective Cohort Study, Journal of Psychosomatic 61 pp. 271-274, 2006.

Mid-Mac Study Measures – Coefficient alphas of .83 – .91 for emotional support from spouse, family and friends indicate good internal reliability (data documentation from Mid-Mac).

MacArthur Successful Aging Study – Two-month test retest data indicate reasonable stability for measures of emotional support (.73) and for levels of demand/criticism (.80), and somewhat lower stability for instrumental support (.44 [.55 for rank correlation]) (Seeman et al, 1994).

 Interpersonal Support Evaluation List – Test-retest data reveal correlations between .77-.86 and internal alpha estimates of .88-.90.

 Canty-Mitchell, J. & Zimet, G.D. (2000). Psychometric properties of the Multidimensional Scale of Perceived Social Support in urban adolescents. American Journal of Community Psychology, 28, 391-400. 

 Zimet, G.D., Dahlem, N.W., Zimet, S.G. & Farley, G.K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52, 30-41. 

 Zimet, G.D., Powell, S.S., Farley, G.K., Werkman, S. & Berkoff, K.A. (1990). Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 55, 610-1

Why America’s unquestioning idolization of Steve Jobs is inappropriate

Steve Jobs, the co-founder of Apple Computer Corporation died today October 6 2011 at the age of 56 from a rare form of cancer of the pancreas. His death has been accompanied by widespread expressions of admiration for the man and his accomplishments. These accomplishments include the creation of Apple Computer Corporation, apple computers, the iPod, iphone and ipad as well also NEXT computer corporations and Pixar animations including Toy Story.   He overcame numerous adversities in his climb to success and fame including being fired from Apple Computer Corporation by a man he hired to manage the company for him while he focused his energies on developing new products.  It is probably fair to say of Steve Jobs that he exemplifies much of what many Americans think is the best about America; opportunity to rise from nowhere to stardom, no silver spoon in his case but lots of hard work and a eye on the goal.  I admired him.  He seems like a good man, there are no terrible stories about him, his company is respected and he is idolized by many.   The cofounder of Apple, Wozniak says, perhaps a bit tongue in cheek, that he’ll “be remembered for the next hundred years as the best business leader of out time.” 

You may be wondering, “where’s the beef”?  Those of you who have read my recent blogs will know that Steve Jobs is a pivot figure in one of the most important aspects of globalization – the offshoring and outsourcing of production to the developing nations of the world. Just as Apple has grown in recent years so have the companies that supply apple with the parts and machines that make Apple a successful corporation. One company that supplies Apple is Foxconn a Chinese firm which now employs more than 1 million workers and is one of the fastest growing companies in the world. They manufacture Ipads and Iphones for Apple. If you have read my earlier blogs you realize that one focus has been on the terrible working conditions at Foxconn Corporation in China. Long work weeks – 12  hours a day x 6 days a week, military like working conditions, low wages, and low employee morale has led to more than 15 suicides in the past year.  One might argue that Foxconn is not Apple. After all, Apple has a “code of practice and conduct” that they claim they hold each company to. Yet, there is little doubt that the pressures to produce products at Foxconn at competitive prices has contributed to these working conditions.  

And now we return to Steve Jobs – the pioneer and great business man – and ask what role does he play in this process that leads to these desperate conditions for Foxconn employees and what responsibility does he have for the conditions that face working people at Foxconn and for that matter in China as a whole? This question is one that has troubled scholars. How much are individual’s (regardless of their position in society) responsible for the exploitation that occurs at the hands of a capitalist economy and how much are they mere “cogs in the wheel” whereby their hands are forced by the pragmatics of business, growth and accountability to shareholders. Some would say that a man with the power of Steve Jobs could have turned his attention and made a difference to the working conditions at Apple’s subcontracted companies.  Why he didn’t consider encouraging Apple to pull its contracts with Foxconn is a story we may now never know. 

Introduction to the Historical Origins of Modern Work Organization

“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.


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 [1].

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) [3]. However, essential hypertension, the leading cause of CVD world- wide [4], 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 [6]. 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) [6].

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”) [11], 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 Influence on the Study of Work-Related Stress

“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 [42], 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 [43], 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 [23], 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 [18].

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)” [44]. 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 [28].

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.

Introduction to Globalization

“Profound changes in the ways in which work is organized and carried out have taken place over the last 200 years, particularly in the Western world and more recently in the rapidly industrializing nations of Asia. Farming and craftwork, which predominated for many centuries, were largely replaced by the industrial revolution, and with it, skilled workers who had once exercised substantial control over their work processes were replaced by lower-skilled labor in new machine- based production technologies [19]. The introduction of Taylorism at the beginning of the 20th century—a new “scientific” approach to maximizing productivity— further reshaped the workplace by breaking down complex, traditional craft-based work processes into small, individual tasks to be performed in a specified amount of time, in a repetitive manner, and controlled by supervisors or mid-level management, leading to the birth of the assembly line. And while originally used for manufacturing, this lead to the assembly line mode of work organization has been transposed to service-sector and white-collar office jobs and to centralized multinational organizations which now divide up work tasks and processes often across national borders. The result of these and other 20th century developments: deskilled workers in many occupations with the power to control the production process increasingly concentrated in the hands of employers and management.

Clearly influenced by globalization, the transformations in work and work organization that began 200 years ago are now accelerating so much as to even be considered another industrial revolution [20]. Globalization has included, among other things: outsourcing of labor to developing countries; feminization of the work force; increases in unemployment, under- employment, and employment insecurity; increases in temporary, part-time, flexible labor—“precarious work”; and a sharp increase in the economic gap between the rich and the poor (see chapter 2). In the 1998 Tokyo Declaration, occupational health experts from Europe, Japan, and the United States described this new world of work—“organization restructuring, mergers, acquisitions and downsizing, the frantic pace of work and life, the erosion of leisure time and/or the blending of work and home time” [21]—and the motor behind it: “. . . driven by economic and technological changes aiming at short-term productivity and profit gain” [21].

The social and economic forces brought about by global economic competition are determining the ways in which work is unhealthy, how noxious it is, and who are most exposed. In fact, these changes disproportionately affect people in lower socioeconomic positions, particularly women and immigrant ethnic minority groups, whose health is already more vulnerable. Women are becoming the poorest component of the workforce, and in turn, the most numerous, being employed in low- income service-sector and manufacturing jobs (see chapter 2). Migrant workers searching desperately for employment are being pulled into developed nations where they often become part of disadvantaged minority groups concentrated in the lowest-skilled work and marginal sectors of the economy that offer minimal or no benefits, such as health insurance.

In industrialized countries, this globalization of the economy over the last 30 years has led to a second round of new systems of work organization, such as lean production [22], and the intensification of work through increased work demands on a reduced workforce.

 Consider some of the following data:

• one-third or more major organizations broadly reduced their workforce in the 1990s and between January 1999 and December 2001;

• 9.9 million jobs were eliminated, and temporary employment multiplied six-fold to nearly three million between 1982-1998 [10, pp. 184-185];

• the average work year for working age couples in the United States has increased by nearly 700 hours in the last two decades of the twentieth century [23], more hours per year than any other industrialized country. Time away from home, due to commuting, has increased significantly while vacation time has decreased [24].

Although little addressed in the United States, these changing working conditions are negatively affecting worker health, indicating that the gains of “lean” production for employers come at a high cost to workers’ health (see chapters 6 and 7). For example, in a 2007 U.S. survey, about three-quarters (74%) of workers at all occupational levels reported feeling stress from work [25]. And this stress proves very costly: disability reported as due to job stress in 1997 (23 days) was four times greater than the median for all other injuries and illnesses combined [26]. In a 1998 study of 46,000 workers, health care costs were nearly 50% greater for employees reporting high levels of stress in comparison to those who were “stress-free” [27].

While the causes of ill health may be in question, the spiraling costs of employee health—both due to work injuries and payment of health insurance—has moved health and work to front and center stage. Clearly, not all stakeholders (e.g., management, labor, employees, government) share the same interest in protecting worker health [12, 15], with many in management/business seeing it primarily as a cost and a drain on profits. More recently, however, efforts are being made to redefine worker health as an investment and source of profit. This book addresses how these social and economic processes are changing both work and the health of working populations.

Notwithstanding the abundant problems around work in developing countries, this book focuses mainly on the detrimental health effects experienced by working people in industrialized countries, particularly in the United States, albeit with the aim that this knowledge can be applied in developing countries as well.

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

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