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Safety is Seguridad: A Workshop Summary Appendix H Occupational Health Among Latino Workers: A Needs Assessment and Recommended Interventions Rafael Moure-Eraso, Ph.D., C.I.H., and George Friedman-Jimenez, M.D. M.P.H. Note: An extended version of this material appeared as Chapter 12: Occupational Health Among Latino Workers in the Urban Setting. In: M.Aguirre-Molina, C.W.Molina, and R.E.Zambrana (eds.). Health Issues in the Latino Community. San Francisco; Jossey-Bass 2001. This manuscript has been updated to 2002. INTRODUCTION The occupational health of Latino workers in the United States is increasingly being recognized as an important area for study as well as for public health and clinical intervention. From a public health perspective this is an important issue to address for several reasons. The Latino population in the United States is sizeable (see Table 1) and growing rapidly, especially in urban areas. Work-related diseases cause substantial morbidity and mortality and are amenable to public health primary prevention interventions, such as the elimination or reduction of the exposures that cause them. Secondary prevention interventions in the form of surveillance and clinical services are also an essential part of the public health approach to occupational health. Although occupational diseases can affect members of all racial and ethnic groups and socioeconomic classes, available evidence suggests that Latino workers, along with other minority workers as well as low-income workers, are at higher risk for occupational disease than other workers in the general population. This excess risk is probably due to over representation of Latino workers in the more hazardous occupations and industries. The resources allocated by the federal government for workers’ health are modest. The National Institute for Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA), and Bureau of Labor Statistics (BLS) have budgets that are smaller by one order of magnitude than the budgets allocated to U.S. federal agencies with comparable missions, such as the Environmental Protection Agency (EPA), and the Food and Drug Administration (FDA). These allocations have consistently proved inadequate to serve the needs of the U.S. workforce in general. Consequently, the occupational health needs of minority workers (e.g., African Americans and Latinos) have been largely unmet with regard to targeted surveillance or primary prevention interventions. Primary prevention is achieved by the elimination or substantial reduction of risk factors that are known to cause workplace death and disease. These interventions can only be successful with the full participation and cooperation of the groups affected by the hazards: workers and companies. A first step is to quantify the dimensions of the problem through hazard surveillance, or collection of systematic data on the prevalence of workplace hazards and populations at risk, followed by specific recommendations for engineering interventions at the point of production to control risk factors. Hazard surveillance should precede disease surveillance for the purposes of primary prevention. Secondary prevention involves the early medical diagnosis and treatment of injury or illness that is successful in achieving recovery and return to work. The data on specific types of morbidity caused by the work environment in the Latino population are very limited, and many Latino workers lack access to available clinical occupational health services. As a result of this
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Safety is Seguridad: A Workshop Summary lack of epidemiological and surveillance data, programs providing clinical occupational health services to Latino working populations have not been developed adequately. This cycle of “no services → no data → no services” can be broken by (1) simultaneously developing epidemiological research and surveillance methods that will effectively include Latino workers and (2) by providing clinical occupational health services accessible by and targeted to Latino working populations. A related topic of growing interest in public health for the Latino population is Environmental Justice (sometimes considered from the perspective of “environmental “injustice”). Environmental justice has focused on the observation that air polluting entities, hazardous worksites, hazardous waste dumps and other sources of environmental pollution are likely to be sited in close proximity to communities of color (Frumkin et al., 1999). There are no systematic, reliable sources of data on occupational diseases in the U.S. working population (Herbert and Landrigan, 2000). Recent peer-reviewed estimates of occupational morbidity and mortality experience for the general U.S. population (1992), not differentiated by race, are substantial (Leigh et al., 1997). Using the best available denominator data for the U.S. working population, we developed an estimate of the number of occupational disease deaths and new cases among Latino workers in the United States. Next, using U.S. and New York City aggregate data, we see that Latino workers are disproportionately employed in the more hazardous occupational categories and under-represented in the less hazardous categories. MINORITIES AS A PERCENTAGE OF THE U.S. WORKING POPULATION The U.S. Census Bureau and the BLS of the U.S. Department of Labor publish population statistics for each year based on population projections from the 1990 census (U.S. Census Bureau, 2000). U.S. census data for 1998 and current statistics (1998) from the U.S. Department of Labor on U.S. occupational injury and illness experience and characteristics provided the basis for Tables 1 through 9. The demographic estimates of the U.S. working population by race and ethnicity appear in Table 1. The U.S. government provides data in Tables 1 through 9 combining race, (e.g., white and black) with ethnicity (e.g., Hispanic). Although not equivalent, we will use Latino for Hispanic and African-American for black. TABLE 1 1998–99 Racial and Ethnicity Distribution of U.S. Population and Civilian Workforce Race/Ethnicity U.S. Civilian Workforce over 16 years old (in thousands) Percent Total U.S. Population (in thousands) Percent Hispanic (Latino) 14,492 10 34,864 12.8 Black 15,334 11 31,355 11.5 White 113,475 81 224,650 84.0 Total 140,863 100 272,820 100 NOTE: Percentages are greater than 100 because Hispanics can also be classified as black or white. SOURCE: Census Bureau (2000) and BLS (2001). It is interesting to note that Latinos are 10 percent of the civilian workforce (older than 16 years old) but 12.8 percent of the total population. In contrast, the African American civilian workforce is 11 percent while their proportion in the total population is 11.5 percent. The proportions of Latinos in both columns appear to show a substantial number of young Latinos (<16 years) not included yet in the civilian workforce.
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Safety is Seguridad: A Workshop Summary Officially, only 5 percent of the Latino population works in agriculture (data on employed U.S. civilian population older than 16 years (DOL, 2000). However, other data sources estimate 12 percent in agriculture (EPA, 1999). A distribution of the 95 percent to 88 percent Latinos employed in occupations not in the agricultural sector shows that more than 67 percent are in blue-collar, low-paying jobs (service, labor and support and sales) while whites hold 56 percent of the same jobs (see Table 2a). TABLE 2a Distribution of Occupations of Employed U.S. Civilian Workers Classified As Hispanic, Black and White Over 16 Years Old in 1994 (in thousands) Hispanic Black White Occupation Number Percent Number Percent Number Percent Professional and managerial 1,517 14.0 2,405 20.2 30,045 28.6 Service (household, protective, other) 2,131 19.8 2,890 23.8 13,207 12.6 Operators, fabricators and laborers 2,474 22.9 2,677 22.0 14,416 13.7 Sales, administration, and technical support 2,639 24.0 3,637 29.9 32,232 30.7 Other 2,082 19.7 537 4.4 15,253 14.5 TOTAL 10,788 12,146 105,190 SOURCE: Modified from EPA (1999). Table 7–3. The most dramatic difference between the two groups is the proportion of Latinos in professional and managerial occupations (white collar) that is half of the proportion of whites in the same category (14 percent Latino vs. 28 percent white). African Americans follow a similar pattern except that their proportion in the professional and managerial classes is higher (20.2 percent) than Latinos. Still the proportion of blue-collar workers among African Americans is the highest at 75 percent. A more recent evaluation of the highest percentage of Latinos in selected occupations appears on Tables 2b and 2c. OCCUPATIONAL DISEASE MORBIDITY ESTIMATE Early estimation of the magnitude of occupational diseases in the United States showed that numbers of new cases could exceed 390,000 per year (Ashford, 1976). More recent estimates show a range of 817,015 to 907,385 of new cases of occupational disease annually. The newer estimate counted first the occupational deaths distributed among four major disease categories: cancer, coronary heart disease, cerebrovascular disease, and pulmonary disease (Leigh et al., 1997) (see Table 3). To this number the authors added cases of non-fatal occupational disease reported by the U.S. Department of Labor’s, Annual Survey of Occupational Illness in 1992, as well as the number of cases reported in the same year by public employees (identified as non-classified occupational disease in Table 3) (Leigh et al., 1997). Because the great majority of cases of occupational disease are not diagnosed as occupational and never become known to the surveillance mechanisms that currently exist, Leigh and colleagues used several indirect approaches to judge the magnitude and severity of the problem. However, the estimate of work-related musculoskeletal disorders, in
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Safety is Seguridad: A Workshop Summary TABLE 2b BLS Labor Force Statistics of Selected Employed Persons by Detailed Occupation and by Race for 2001 Occupation Non-Agricultural Total (thousands) Hispanics % Blacks % Total working population 135,073 10.9 11.3 Professionals 41,894 5.1 8.3 Managers 5,139 5.7 9.7 Services 18,359 16.3 17.9 Household services 239 32.8 12.1 Food preparation 657 27.0 16.4 Cooks 2,073 24.0 17.4 Auto body repair 220 20.8 5.4 Health care services 2,680 11.5 29.4 Construction 6,253 17.4 7.0 Plasterers 58 46.9 12.2 Concrete work 117 38.4 13.9 Drywall 191 35.1 8.6 Tile 93 29.8 4.0 Painters 636 28.5 7.6 Brick and stone masons 235 24.5 11.2 Precision food manufacture 429 31.2 13.5 Meat cutters 223 38.1 13.5 Food batch makers 55 15.0 12.0 Manufacturing (textiles and general) 17,698 17.7 15.6 Sorter and grader 128 34.1 17.6 Packing 301 31.9 21.5 Cutting and slicing operators 138 24.3 16.3 Machine operator 2,515 20.4 16.6 Assemblers 1,135 18.6 15.5 Textile sewing operators 368 38.3 13.5 Textile other machine operators 197 26.1 14.7 Dressmakers 92 21.1 8.1 Upholsterers 62 28.2 10.9 Pressing 71 36.8 29.0 Dry cleaning 205 25.3 20.1
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Safety is Seguridad: A Workshop Summary TABLE 2c BLS Labor Force Statistics of Selected Employed Persons by Detailed Occupation and by Race for 2001 Occupation Agricultural, Forestry, and Fishing Total (thousands) Hispanics Percent Blacks Percent Agriculture, forestry and fishing 3,245 21.5 5.0 Owners and managers 1,108 3.6 0.9 Agriculture and related activities 2.004 32.6 7.1 Other agricultural workers 734 42.8 3.6 Farm hands 671 42.3 3.7 Farm industrial work 1,269 26.7 9.1 Gardeners 876 29.5 11.1 Graders and sorters 51 68.0 7.9 SOURCE: Modified from BLS. Table 11. Employed Persons by Detailed Occupation, Sex, Race, and Hispanic Origin at<ftp://ftp.bls.gov/Pub/special.request/If/aat11.txt>. TABLE 3 Estimated Occupational Disease Morbidity for Blacks and Hispanics Working in the United States, 1992 Disease Categories Estimated No. of Occupational Illnesses Attributed to Occupation (Includes all races and ethnicity) Estimated No. of New Cases of Occupational Illnesses Attributed to Occupation for Blacks (11%) Estimated No. of New Cases of Occupational Illnesses Attributed to Occupation for Hispanics (10%) Cancer 66,790–111,130 7,347–12,244 6,679–11,113 Coronary heart disease 36,500–73,000 4,015–8,030 3,650–7,300 Cerebrovascular disease 5,050–14,400 556–1,584 505–1,440 Chronic obstructive pulmonary disease 150,000 16,500 15,000 Sub-Total 258,340–348,710 28,418–38,358 25,834–34,853 Unclassified Occupational Illnessa 538,675 61,454 55,867 TOTAL 817,015–907,385 89,872–99,812 81,701–90,720 aThis category includes BLS occupational illness for 1992 and occupational illness reported in the same year by the U.S. government employees (see Leigh et al., 1997). SOURCE: Leigh et al. (1997). Percentages from BLS (1999). particular, was likely not corrected sufficiently for known under-reporting in administrative record-keeping systems (Silverstein et al., 1997; Punnett, 1999). Thus, the totals more likely underestimate the true values. For the purpose of estimating Latino work-related morbidity we assume that the percentage of disease in Latinos and African Americans correspond to their percentage in the civilian labor force (10 percent and 11 percent respectively) (DOL, 1999). Applying the 11 percent estimate, the range of new cases for Latinos would be between 81,701 and 90,720 for the year 1992 (see Table 3). There is no reason to believe that this yearly estimate has changed since the reported numbers for 1992.
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Safety is Seguridad: A Workshop Summary In addition, other occupational diseases such as occupational asthma (included under chronic obstructive respiratory disease in Table 3) are considered, the morbidity total grows substantially. Other researchers (Milton et al., 1998; Wagner and Wegman, 1999) have estimated that as high as 21 percent of all cases of asthma have an occupational etiology, yielding estimates above 100,000 prevalent cases of occupational asthma in the United States. This translates into at least 10,000 possible cases of occupational asthma among Latino workers in the U.S., if the 10 percent proportion for Latinos working in the United States. A more focused look at the occupations with the greatest number of injuries illustrates the proportion of Latinos in those categories (see Table 4a). The U.S. Department of Labor, Bureau of Labor Statistics, identified the 10 job categories with the highest numbers of injuries and illnesses among 1,883,380 cases analyzed in 1997 (DOL, 1999). Latino workers were overrepresented in at least three of the most hazardous job categories: janitors, laborers, and cooks. TABLE 4a Percentage of Hispanics in 10 Occupations with the Larger Number of Occupational Injury and Illness 1997 Number Occupation Cases Percent Hispanic All occupations 1,833,400 10.2 Truck drivers 145,500 6.3 Laborers (Non-construction) 106,900 11.5 Nurses aides 91,300 7.6 Janitors and cleaners 45,800 20.0 Laborers (construction) 45,800 17.9 Assemblers 44,300 9.7 Carpenters 37,100 8.2 Cooks 31,500 12.8 Stock handlers 29,200 7.7 Welders and cutters 28,400 8.4 SOURCE: BLS (1999). More specific data on rates of occupational injuries and illness appear in Table 4b. This table provides the incidence rate of injuries and illness per 10,000 full-time-equivalent workers. In general, the Standard Industrial Codes (SIC) that define the industry with higher incidence rates correspond to the SICs with the highest percentage of Hispanics. It is also remarkable that the greatest (>70 percent) contributor to the incidence rate of occupational illness is repetitive trauma illness. The only exception is agriculture. OCCUPATIONAL MORTALITY ESTIMATIONS Fatal Occupational Injuries The U.S. Department of Labor compiles every year the number of traumatic fatalities by race within the U.S. civilian workforce over 16 years old (DOL, 2000). Traumatic occupational fatalities are deaths that occur during employment or in the course of employment and are caused
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Safety is Seguridad: A Workshop Summary TABLE 4b Incidence Rates per 10,000 Full-Time-Equivalent Workers of Non-Fatal Injuries and Illnesses by Selected Industries and Cases in 2000 Industry SIC Code Injury Ratea Illness Rateb Repetitive Trauma Illness Rateb Percentage Hispanic in Industryc All private 580 39.4 26.3 10.9 Agriculture 01–02 680 31.3 6.7 21.5 Metal mining 10 460 27.6 23 11.9 Coal mining 12 710 45.4 28.5 11.9 Construction 15 820 10.4 10.7 17.4 Non-ferrous foundries 336 1390 105.9 77.3 9.8 Auto stamping 3465 1260 267.9 240 9.5 Motor cars 3711 1440 831.2 727 17.7 Food products 20 1020 213 181 31.2 Meat products 201 1190 553.9 485 38.1 Meat packing 2011 1550 921 812 38.1d Sausage and meats 2013 1160 311 274 31.2d Poultry slaughtering 2015 990 433 378 31.2d Men’s trousers 2325 530 245 224 21.1 aThe occupational injury incidence rates (IR) represent the number of injuries per 10,000 full-time workers and were calculated as: IR=(N/EH)*20,000,000 Where: N=number of injuries; EH=total hours worked by all employees during the calendar year and 20,000,000=base for 10,000 full-time-equivalent workers (working 40 hours per week, 50 weeks per year) (Based on BLS Tablel, OSTB12/18/2001, Incident Rates of Non Fatal Occupational Injuries by Industry Selected Cases at <www.bls.gov.iif/oshwc/osh/os/ostb1001.txt>). bThe occupational illness incidence rates (IR) are calculated as above. Data from: BLS Table S14. Nonfatal occupational illness incidence rates by industry and category of illness, 2000 at<http://www.bls.gov/iif/oshwc/osh/os/ostb1005.txt>. cData from USDOL #11. Employed persons by detailed occupation, sex, race, and Hispanic origin at <ftp://ftp.bls.gov/pub/special.requests/lf/aat11.txt>. dEstimates based on (c) above. by acute incidents related to the victim’s occupation. The first three columns of Table 5 present these data for 1998. The proportion of fatalities occurring to Latinos (12 percent of 6,026) is greater than the expected proportion corresponding to the percentage of Latino workers in the working civilian population (10 percent of 132,684,000). If the fatality rate were proportionate to the number of Latinos in the workforce, 10 percent or 603, fatalities would be expected, while 700 were observed. The 97 deaths in excess over the expected number, or a relative risk (Gardner, 1989) of 1.18, indicate that Latinos are 18 percent more likely to die a traumatic death from injury on the job than whites and African Americans combined. A similar analysis could be made for the 2000 data. What appears more dramatic in the 2000 data is the substantial increase of mortality rate per 100,000 workers among Hispanics. Rates increased by 11.3 percent from 1999 to 2000. The proportion of Hispanics fatalities has also increased substantially (33 percent) when compared with the white rates. Fatality rates for blacks and whites have both decreased while the Hispanic rate increased.
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Safety is Seguridad: A Workshop Summary TABLE 5 Occupational Traumatic Fatalities (Numbers and Rates) for White, Black, and Hispanic Working Populations for 19982 and 20001 Race and Ethnicity Fatal Injuries No. (percent)* U.S. Civilian Workers over 16 years old (thousands) no. (percent)* Rates per 100,000 1998 2000 1998 2000 1998 2000 White 5,016 (83) 4,240 (72) 111,683 (84) 113,475 (81) 4.491 3.737 Hispanic3 700 (12) 815 (14) 13,381 (10) 14,492 (10) 5.231 5.624 Black 591 (10) 574 (10) 14,795 (11) 15,334 (11) 3.995 3.743 Total 6,026 5,915 132,684 140,863 4.541 4.199 NOTES: 1. The Hispanic fatality rate grew by 11.3 percent from 1999 to 2000 (5.213 to 5.623). In addition, in 1999 the Hispanic fatality rate was 16.7 percent greater than the white fatality rate (5.231 compared with 4.484). The disparity between the Hispanic and white fatality rates grew to 33.0 percent in the year 2001 (5.623 compared with 3.763).2. Percentages are greater than 100 because Hispanic workers can also be identified as black and white. SOURCES: BLS (1999, 2001). Because, since the Latino classification in the Bureau of Labor Statistics includes members of every race (and thus the percentages sum to more than 100 percent), no valid statistical test could be applied to measure differences in fatal occupational injury rates by race/ethnicity. To bring some context to these traumatic fatalities, the Bureau of Labor Statistics reports the event or exposure to which each death is directly attributed (i.e., the underlying cause) (see Table 6). Transportation incidents are by far the principal cause of traumatic occupational fatalities (44 percent), followed by homicide (16 percent) and being struck by objects and equipment in work settings (15 percent) (DOL, 2000). Unfortunately the BLS statistics only provide the distribution of all deaths by race/ethnicity, without stratification by event or exposure. In order to have a benchmark the number of traumatic deaths were estimated within each race/ethnicity by event or exposure, assuming the same percentages as the total number of deaths. These numbers are thus only an approximation, since the distribution of occupational titles differs between African Americans, whites and Latinos. In recent studies estimates of fatal injury lifetime risk accumulated over the life of the worker have been calculated (Myers et al., 1998). In 1998 the NIOSH published a study comparing experiences of the highest working lifetime risks by race/ethnicity that permits a direct comparison between Latinos, African Americans and whites (see Table 7). All comparisons were made between lifetime risks of African Americans and whites in the same occupation/industry categories. In Table 7 the descending list of the highest fatal working lifetime risk for Latinos in five occupations within five industries is compared with the same occupation and industry lifetime risk experiences of African Americans and whites. Latinos had the highest lifetime risk of fatalities by homicide among cashiers in gas stations, guards in security services, and collisions as truck drivers. Latinos also had the second highest lifetime risk of homicide as cab drivers and employees of grocery stores (Myers et al., 1998).
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Safety is Seguridad: A Workshop Summary TABLE 6 Occupational Traumatic Fatalities by Event or Exposure, 1998: Hispanic (Latino), Black and White Populations Estimation of Fatalities by Race and Ethnicity Event or Exposure BLS 1998 Percent Events Hispanic Transportation incidents 2,630 44 308 Assault, violence 960 16 112 Contact objects and equipment 949 15 105 Falls 702 12 84 Exposure electricity toxins 572 9 63 Other 213 3 28 Totals (from Table 4) 6,026 700 NOTES: 1. BLS obtained the distribution of “Percent Events” over all races and ethnicities. BLS reported the distribution of race and ethnicity of all the 6,026 fatalities as “Percent Events” with no breakdown by race and ethnicity. 2. The estimation of numbers of deaths by event and by race and ethnicity was based on “Percent Events” of all fatalities (i.e., calculation of estimate of transportation fatalities of Hispanics: 700*0.44=308). SOURCE: BLS (1999). TABLE 7 Highest Working Lifetime Fatality Risk for Homicides and Transportation Incidents for Hispanics, Black and White Workers—(Accumulated Data from 1992–96 for Deaths Greater than Five) Hispanic Black Industry Occupation Event # Deaths Lifetime Risk # Deaths Lifetime Risk Cab or transportation Driver Homicide or shooting 46 49.5 137 66.7 Gas station Cashier Homicide or shooting 12 13.1 6 4.5 Grocery store Employee Homicide or shooting 52 12.2 30 7.2 Security service Guard Homicide or shooting 31 9.5 41 4.5 Truck or transportation Driver Collision 28 4.9 42 4.2 NOTES: 1. Working lifetime risk (WLTR) in units of deaths per 1,000; 45-year working lifetimes WLTR=[1−(1−R)y]×1000 where R=Ratio of the average annual number of work-related fatal injuries among workers in a given group to average annual employment in that group; y=Years of exposure to work-related fatal injury risk. 2. Working lifetime is assumed to start at 20 and end at 65 years. 3. NA=not applicable. SOURCE: Modified from Myers et al. (1998). Fatal Occupational Diseases Fatal occupational disease is defined as death due to a disease that is either caused or exacerbated by substances, physical conditions, or other hazardous exposures on the job. The best available estimates of fatal occupational disease in the U.S. general population were published recently by Leigh et al., (1997). Their estimates considered six groups of occupational diseases: cancer and cardiovascular, renal, neurological, pneumoconioses, and chronic respiratory diseases in which occupational exposures were the prime contributor to death (see Table 8). They
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Safety is Seguridad: A Workshop Summary estimated that 46,800 to 73,600 deaths per year in the United States due to occupational diseases (see Table 9). TABLE 8 Estimated Fatal Work-Related Disease for the White, Black, and Hispanic Working Populations Race/Ethnicity Fatal Work-Related Disease Range Percent White 38,844–73,600 83 Black 4,680–7,360 10 Hispanic (Latino) 5,148–8,096 12 Total 46,800–73,600 100 NOTE: Percentages are greater than 100 because overlap of counting racial classifications (e.g., Hispanics can be double counted as whites and blacks. SOURCES: BLS (1999) Percentages of traumatic fatalities as reported by BLS for 1998. Modified from Leigh et al. (1997). TABLE 9 Estimated Fatal Work-Related Illness Distributed by Disease Causes of Death Estimated No. of Deaths Attributed to Occupation (all races and ethnicity) No. of Deaths of Hispanics Attributed to Occupation (12%) No. of Deaths of Blacks Attributed to Occupation (10%) Cancer 31,025–51,706 3,723–6,204 3103–5171 Cardiovascular and cerebrovascular disease 5,092–10,185 611–1,222 509–1,019 Chronic respiratory diseases 9,154 1,099 915 Pneumoconioses 1,136 136 114 Nervous system disorders 269–806 32–96 27–89 Renal disorders 223–689 27–83 22–76 Total 46,800–73,600 5,520–8,832 4,680–7,360 SOURCES: Leigh et al. (1997); BLS (1999). These estimates are more conservative than the previously published estimates of 100,000 deaths annually (Ashford, 1976). Using the BLS estimate for 1999 (DOL, 2000) stating that 12 percent of the traumatic fatalities in the U.S. civilian workforce were of Latino workers (see Table 5), we can roughly estimate that 5,520 to 8,832 Latinos die from occupational diseases annually. The same 1997 estimates by Leigh et al. of deaths by occupational disease are distributed by cause of death using the percentages of death for traumatic fatalities (12 percent for Latinos, 10 percent for African Americans). The results appear in Table 8. QUALITY OF DATA ON LATINO WORKERS All federally generated data on morbidity and mortality are based on reported counts for a limited number of workers in the private sector only (excluding self-employed workers). For any
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Safety is Seguridad: A Workshop Summary overall estimation, adjustments (e.g., additional data sources) need to be made to arrive at total counts for the entire work force. Unreported and uncounted cases generally lead to underestimation of occupational morbidity and mortality. A second estimation is required because of the inadequate recording of race/ethnicity, necessitating the assumption that the risk of occupational disease and injury is the same in the U.S. Latino workforce as in the general U.S. workforce. Because evidence strongly suggests that Latinos are over-represented in the more hazardous jobs and are at higher risk, the true numbers are likely to be even higher. Landrigan and Markowitz (1989) estimated the degree of under-reporting by comparing independently generated estimates of occupational disease mortality and incidence with the actual numbers of cases reported by the Workers’ Compensation Board. In New York State, only 3 percent to—5 percent of the estimated number of deaths due to occupational diseases was reported by the Workers’ Compensation Board as being of occupational etiology. Similarly, 11 percent to—38 percent of the estimated number of incident cases of occupational disease were reported by the Workers’ Compensation Board as occupational. Many of the estimated 95 percent to- 97 percent of occupational disease deaths and 62 percent to—89 percent of incident cases of occupational disease that were not reported as occupational probably represent unrecognized epidemics. COSTS OF OCCUPATIONAL MORBIDITY AND MORTALITY Missed and delayed diagnoses of occupational disease produce substantial and avoidable costs in the form of time lost from work, decreased productivity, economic hardship and unemployment, increased burden on an already overloaded health care system, inappropriate diagnostic testing or treatment, prolonged duration of disease, progression of reversible disease to chronic irreversible disease, and most important, suffering, disability, and death. The hidden costs are borne mainly by workers and their families; employers; union benefit funds; city, state, and federal governments; and in some cases, medical insurance companies (who pass the costs on to their other clients). These costs contribute to the rising costs of medical insurance. In addition, the missed diagnoses are not reported as occupational diseases and are thus invisible to the occupational health surveillance systems, delaying recognition and resolution of the problem of work-related disease. Leigh et al. (1997) estimated that the total cost of occupational morbidity and mortality in the United States reaches $171 billion per year: $65 billion in direct costs plus $106 billion in indirect costs. The grim share of this cost from the Latino working population is approximately 12 percent (Leigh et al., 1997) of $171 billion, or $21 billion dollars each year. WORK-RELATED DISEASES IN LATINO WORKERS Which work-related diseases occur in Latino workers in urban areas of the United States? Specific statistics of incidence, prevalence, and mortality data for Latino work-related diseases have not been compiled. However, some examples of work-related diseases that occur in industries and occupations that employ many Latino workers are listed as “occupational sentinel health events” (Rutstein et al., 1983; Mullan and Murphy, 1991). Occupational sentinel health events are diseases or causes of disability or death (with ICD-9 codes) that satisfy defined criteria for literature-supported associations with specific toxic substances, industries, or occupations. In individual cases a detailed occupational health clinical evaluation (as discussed in several occupational medicine textbooks (LaDou, 1998; Rosenstock, 1996; Levy, 1999; Rom, 1998) is indicated once a work-related disease is suspected, in order to clinically confirm or rule out work-
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Safety is Seguridad: A Workshop Summary relatedness. In addition, sixteen reviews of clinical evaluation for specific occupational diseases have recently been published in the American Journal of Industrial Medicine (January 2000). LATINO WORKERS RISK OF OCCUPATIONAL DISEASE Table 4a shows the blue-collar occupations with the highest number of occupational illness and injury nationwide. These 1997 data show how the percentage of injuries/illness exceeded the representation of Latino workers in three categories (janitors, laborers, and cooks) (DOL, 1999). Another approach to judging the magnitude of the problem of occupational disease in Latino workers is to examine data on the rates of occupational disease in various industries and the presence of Latinos in these. A sample of that strategy appears on Table 4a. SWEATSHOPS IN THE GARMENT INDUSTRY Sweatshops have been discussed in two documents published recently by the U.S. General Accounting Office, which defines them as “businesses that regularly violate both safety or health and wage or child labor laws” (GAO, 1988); sweatshops and are also defined more loosely as “chronic labor law violators.” Construction firms, farms, and homework (e.g., piecework apparel or electronics manufacturing in the home) are included in the definition. By definition sweatshops are hazardous workplaces. The occupational hazards encountered in sweatshop work in the garment industry include ergonomic hazards (e.g., repetitive motions, awkward working postures, vibrating tools such as fabric cutters, falls from ladders), airborne hazards (e.g., high concentrations of dusts, poorly ventilated dry-cleaning solvents and fumes from glues and fabric treatments like formaldehyde), temperature extremes, and skin contact with irritant and allergenic substances. Occupational diseases and injuries prevalent among apparel sweatshop workers include musculoskeletal or cumulative trauma disorders like back, neck and shoulder pain and carpal tunnel syndrome (Punnett et al., 1985; Sokas et al., 1989), contact dermatitis, occupational asthma and bronchitis, vibration-induced Raynaud’s phenomenon, and acute and chronic toxicity from solvents and other toxic chemicals. A poll of 53 federal enforcement officials, published by the U.S. General Accounting Office (1988), showed that sweatshops were reported in significant numbers in 47 of the 50 states, most commonly in the apparel, restaurant, and meat processing industries. Major concentrations were found in large cities, with New York the most intensively studied. At the national level Latinos were thought to make up the majority of sweatshop workers in both restaurant and apparel industries, followed by Asians and African Americans. No national estimates of the number of sweatshop workers have been published, but local estimates from several sources have been reported. The director of the N.Y. State Department of Labor Apparel Industry Task Force estimated that 4,500 of the 7,000 apparel factories and shops in New York City were sweatshops, and that over 50,000 workers were employed in this sector. Other sources estimated the number of apparel sweatshops at 3,000, also with over 50,000 sweatshop workers (GAO, 1988). In New Orleans an estimated 25 percent of the 100 apparel firms (employing 5,000 or more workers) were multiple labor law violators. The only available estimate for restaurant workers comes from an official in Chicago, who estimated that half of their 5000 restaurants (employing 25,000 or more workers) were chronic labor law violators (GAO, 1988). Sweatshops have proliferated because of continuing social and economic factors. The reasons for the existence of sweatshops cited by more than 50 percent of the federal officials (GAO, 1988) were (in decreasing order of response):
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Safety is Seguridad: A Workshop Summary available supply of an immigrant workforce labor-intensive nature of the industries low profit margin in these industries too few inspectors weak or nonexistent unions inadequate penalties for infractions Not mentioned but probably important is the fact that these industries require skills that are either already possessed by a large proportion of the immigrant workforce or can be learned on the job with little formal training. This does not imply that these are low-skilled jobs; Fernandez Kelly gave a graphic description of the high level of skill and productivity needed even to approach earning the minimum wage in a piecework payment system (Fernandez-Kelly, 1983). Sweatshops have also been identified as a system of production that invariably inflicts violence on minorities, either traumatic violent deaths and injuries (fires, explosions, accidents) or chronic occupational diseases that although extended in time are not less violent (Moure-Eraso, 1999). MAQUILADORA INDUSTRY AS MODERN SWEATSHOPS Closely related to sweatshops are maquiladoras, manufacturing and assembly factories along the Mexican side of the U.S.-Mexico border. The maquiladora produces a variety of goods (from Zenith television sets to computer boards and wire harnesses) earmarked exclusively for export to the United States. More than one million workers work in this industry (Cedillo, 1999). These workers are exclusively Mexican citizens working in the Mexico side of the border. The community and occupational health impacts have been studied only in the last 10 years of its explosive growth. A community study of 267 maquiladora workers, mostly female, in the cities of Matamoros and Reynosa found evidence of musculo-skeletal disorders related to working conditions (pace of work, poor workplace design, and ergonomic hazards). Acute health effects were also identified compatible with chemical exposures. Although other chronic diseases were not apparent, the high presence of musculo-skeletal disorders was a striking result for a very young workforce (average age 25 years) (Moure-Eraso et al., 1994, 1997). BARRIERS TO PREVENTION OF OCCUPATIONAL DISEASES The evidence presented above strongly suggests that occupational disease in the Latino workforce is a common, severe, and preventable problem. In order to suggest rational solutions to the problem it would be helpful to explore some of the barriers to prevention of occupational diseases as well as some of the reasons that Latino workers tend to be over-represented in hazardous jobs. In principle all occupational diseases are preventable. Prevention depends on identifying the causal exposure(s) and eliminating or reducing these exposures until no more workers get sick. Effective prevention requires timely identification and elimination or control of the causative exposures. It is preferable to try to prevent the disease from occurring at all, rather than allowing it to occur and then trying to rehabilitate the person and provide monetary compensation for damage already done. Several types of barriers currently exist to prevent implementation of effective prevention strategies. A lack of scientific understanding of the causal agents and their mechanisms is one important barrier, and research must be ongoing to identify hazardous agents and work situations. For example, only about 10,000 of the 60,000 commercially used chemicals have been tested for
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Safety is Seguridad: A Workshop Summary toxicity in animals (LaDou, 1998), and very few of these have been studied epidemiologically in humans. Understanding of the cellular and molecular mechanisms of toxicity is clearly an important component in developing new approaches to treatment and prevention of occupational disease. Even so, results of epidemiological studies can often be used to prevent occupational disease even without detailed knowledge of mechanism. An example is the identification of asbestos-related diseases using epidemiological methods. This knowledge led to the reduction in asbestos-related disease through regulation and decreased use of asbestos in the United States. Other situations may not be so clear-cut, and it may require more sophisticated epidemiological techniques (e.g., preventive intervention trials) or basic understanding of the toxicology to identify the causative agent. Although an incomplete understanding of the biomedical and epidemiological etiologic agents causing specific occupational diseases are important factors, the main barriers to prevention have been economic, political, legislative, and social. Frequently workers cannot afford to turn down a job for which they are qualified, simply because it is hazardous; they often are unable to leave a job they know is hazardous, because they do not have the financial resources to stop working for the time required to find another job, retrain for another job, or to apply for and receive Workers’ Compensation payments. It is an unfortunate fact that Workers’ Compensation payments for occupational diseases generally take more than six months, and often over a year, to begin, even in the most clearly documented cases. Although this barrier affects relatively affluent workers as well, it affects workers with less financial resources more severely. In addition, the threat of prolonged unemployment weighs heavily on members of communities where jobs are scarce. The need to continue supporting a family frequently serves as an irresistible pressure on workers to endure concrete physical discomforts or more abstract elevated risks of occupational diseases. As a result workers in these circumstances may present with advanced or late-stage occupational diseases and may be resistant to quitting their jobs even when strongly counseled to do so by a physician. This economic and bureaucratic trap is a major barrier to preventing occupational illness in Latino workers. Employers who are ethical, well informed about occupational health, and sensitive to the particular needs of their workforces can play a key role in providing safe and healthy workplaces. Labor—anagement health and safety committees can be helpful in raising issues and resolving them before serious health effects occur. Employers sometimes believe that improvement of working conditions will be prohibitively expensive and will not make the investment, even if their workers are getting sick from exposures on the job. In spite of this common perception that safe and healthy working conditions cost too much, sometimes the cost of directly eliminating the hazard is less than the combined long-term costs of decreased productivity due to time lost from work and low morale, increased Workers’ Compensation premiums, and fines from enforcing agencies like the OSHA or the EPA. Sometimes a “win-win” solution can be found that improves the working conditions without incurring unmanageable costs and may even increase productivity (Friedman-Jimenez and Claudio, 1998). Lack of access to comprehensive clinical occupational health services is another barrier to recognition and prevention of occupational diseases. Access is difficult for most workers, particularly so for Latino workers. Evidence for this is indirect, since direct measures of access to these services have not been published. The increased risk of occupational disease combined with poor access to clinical, preventive, and educational occupational health services suggests that the public health impact of interventions to correct this situation would be particularly great. Overcoming the socioeconomic and political barriers to prevention may prove to be an even greater challenge for Latino workers than for white workers, and will not occur until the problem is recognized and adequate resources are committed to a rational solution.
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Safety is Seguridad: A Workshop Summary A COMPREHENSIVE APPROACH TO ADDRESSING OCCUPATIONAL DISEASE IN LATINO WORKERS The evidence strongly suggests that preventable occupational diseases cause substantial mortality and morbidity in the U.S. Latino population, and that this problem is not being recognized or addressed adequately. Admittedly the evidence is fragmented and of variable quality, but it is more than sufficient to drive us to begin addressing this problem now. The economic and non-economic costs of not addressing the problem are great. The OSHA has not been effective in identifying hazardous exposure situations or epidemics of occupational disease, as we have seen in the report on sweatshop inspections. We need to address the problem directly and break the cycle of “no services → no data → no services”, by making comprehensive occupational health services more accessible to Latino workers and simultaneously documenting the epidemics with careful clinical, epidemiological, and surveillance studies of working populations that include significant numbers of Latino workers. To facilitate this process recommendations are offered for a comprehensive approach to addressing this problem. These recommendations fall into six categories: primary prevention intervention approaches; clinical services; educational approaches; research and surveillance; unionization and organization of workers; and legislation and regulation of hazardous workplace exposures. To have a significant impact on the occupational health of Latino workers efforts must be made in all six areas. Although occupational diseases may disproportionately affect Latino workers, the aim of preventive programs should be to reduce hazards for all workers, not simply redistribute the hazards more “equitably.” These recommendations are intended to supplement broader, ongoing efforts to improve health and safety conditions in the workplace. Primary Prevention Interventions Occupational health is looking more and more to primary prevention interventions as the way to evolve from a paradigm of control of occupational exposures to a new one of prevention (Moure-Eraso, 1999; Quinn et al., 1998). For example, traditional industrial hygiene has at the top of the hierarchy of engineering interventions the fabrication of local exhaust ventilation systems to “control” chemical exposures in work environments. Such strategies are proving to be very problematic in the long run. The ventilated (exhausted) toxic substance extracted from the worksite becomes an environmental contaminant in the community. This method of control generates toxic pollutants (gases or tiny particles) that need to be treated as either a hazardous waste or an air pollutant. In environmental science that approach is defined as an end of pipe solution equivalent to waste disposal. New strategies for engineering interventions are being developed that avoid this type of risk transfer. The most obvious one for primary prevention purposes is raw material substitution. If this is not viable, toxic use reduction or source reduction by process changes are the strategies of choice (Moure-Eraso, 1999; Ellenbecker, 1996). Housing in minority communities often clusters at factories and emitters of pollutants. Risk shifting from the point of production can be avoided or at least mitigated by such primary prevention strategies as substitution, source reduction, closed-loop recycling, improvement of maintenance, process modernization, reformulation of products, and improvements of housekeeping and training changes (Moure-Eraso, 1999; Ellenbecker, 1996). All these
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Safety is Seguridad: A Workshop Summary interventions need to occur at the point of production and with full participation of the parties involved (i.e., workers, companies, and occupational health professionals). CLINICAL OCCUPATIONAL HEALTH SERVICES Access to comprehensive clinical occupational health services is probably the major determinant of the success of medical treatment for occupational diseases, as well as of surveillance and secondary prevention programs. In New York City and other urban areas in the United States, working Latinos have even less access to these services than the general working population. Access is determined mainly by the existence of local occupational health clinics and primary care providers knowledgeable in occupational medicine, as well as existence of other referral sources, such as concerned unions, and workers and businesses aware of occupational health. Occupational diseases are usually only recognized when the diagnoses are specifically considered by clinicians with some training in occupational medicine, or when suggested by an educated worker or patient. Comprehensive occupational health services should include: diagnosis and symptomatic treatment of the medical condition; determination of whether the medical condition is work-related and identification the causative exposure(s) as specifically as possible; evaluation of workplace conditions, including inspection of the workplace if necessary and feasible; the capability to mount a group medical screening of co-workers from the same workplace with similar exposures, if indicated; education of the worker or patient as well as the employer and union regarding occupational hazards; gaining the cooperation of the employer and the union in addressing health and safety issues on the job; removal or control of the hazardous exposure by materials substitution, engineering controls, personal protective equipment, or if this proves impossible, removal of the worker from the workplace; filing Workers’ Compensation applications when appropriate; if necessary and with the worker’s informed consent, reporting hazardous workplaces to the OSHA, NIOSH, EPA, or the appropriate regulatory or research agency; reporting all cases to the appropriate surveillance program if one exists (e.g., Occupational Disease Registry of the New York State Department of Health, or the NIOSH Sentinel Event Notification for Occupational Risk (SENSOR) program (Baker, 1989); facilitating vocational rehabilitation and job retraining for workers disabled by occupational diseases (e.g., workers with allergic sensitizations to substances present at the worksite); educating primary care providers about recognition, basic management, and referral of patients with likely occupational diseases. Clinical services for most Latinos begin with primary care providers in the Latino communities, including practitioners, health centers and providers in hospital outpatient departments and emergency rooms. The majority of primary care providers have never been trained to recognize occupational diseases and do not know how or where to refer a patient they think may have an occupational disease. Education of hospital-based providers is important, but education of the community-based providers is crucial, since they are often the first or only
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Safety is Seguridad: A Workshop Summary accessible source of health care and advice. If the first contact providers do not recognize the occupational etiology of the illness, it is unlikely that the correct diagnosis will be made at all. These providers should have a basic knowledge of the diagnoses they might encounter that are likely to be work-related, the occupational sentinel health events discussed earlier. Appropriate referral channels must be accessible to the providers to follow up on possible work-related diagnoses. The Association of Occupational and Environmental Clinics (AOEC), based in Washington, D.C., has over 60 clinics across the United States available for referrals from primary care providers. The New York State Department of Health supports a network of eight occupational health clinics that see patients referred by community health care providers, employers, unions, and other sources, including self-referrals. EDUCATIONAL APPROACHES Much is already known about workplace hazards and prevention (see Rom, 1998; Rosenstock and Cullen, 1996; La Dou, 1998; Levy and Wegman, 1999; DiNardi, 1998). Application of this knowledge to improve public health requires effective education of professionals, workers, and employees. Comprehensive, culturally and linguistically competent occupational health education programs should be accessible to all workers in specific industries and occupations. To be accessible to Latino workers these programs need to be in Spanish and English and should include Right-to-Know education, other health and safety training, and Spanish translations of relevant material safety data sheets (MSDSs). An excellent book by A.Kimball (1990) which lists and reviews 289 Spanish-language occupational health and safety materials for workers, is a useful aid in planning and conducting worker education programs for Spanish-speaking Latino workers. Literature on empowerment approaches to worker health and safety education by Wallerstein et al. (1992 and 1993) emphasizes active involvement of workers in creating solutions to health problems in their own workplaces. Employers are often not well versed in health and safety issues, even related to hazardous substances or conditions in their own facilities. Educational programs to make them aware of appropriate health and safety practices and to sensitize them to worker concerns and perspectives will facilitate improvements in health and safety conditions. Many corporate and union health and safety departments have been downsized or eliminated. Occupational health programs in academic centers or in the community (e.g., Committees for Occupational Safety and Health) could play increasingly important roles in meeting occupational health training needs. Limitation of job opportunities due to lack of education is important as an independent factor, and in combination with other factors, in increasing the risk of occupational diseases in Latino workers. Improvement of both quality of education and numbers of high school and college graduates in Latino communities would help lower the risk of occupational disease by opening up opportunities for less hazardous jobs and by empowering workers to improve their working conditions. RESEARCH AND SURVEILLANCE Sufficient evidence exists to justify addressing the problem of occupational disease in Latino workers immediately. Nevertheless, for this issue to compete successfully with other high-priority issues for funding and research and clinical talent, objectives of this research would be (1) to determine which occupational health issues are most pressing; (2) to document the extent and severity of the problem; and (3) to develop effective and practical solutions.
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Safety is Seguridad: A Workshop Summary The NIOSH has called to the occupational health community to develop a National Occupational Research Agenda (NORA) to address the financial and human challenges brought about by the large burden of work-related disease, injury, and death. This agenda has developed 21 research priorities that includes categories of special importance to the Latino community; special populations at risk; occupational health services; social and economic consequences of workplace illness and injuries; and innovative methods of hazards and health surveillance (NIOSH, 1998). NIOSH has organized periodic meetings with more than 500 organizations and individuals to obtain input for the development and guidance of research programs under NORA. Improving access of Latino workers to occupational medicine clinical services would help greatly in documenting the prevalence and incidence of currently undiagnosed occupational diseases in Latinos. A successful statewide network of occupational health clinics coordinated by and reporting to the state department of health and supported by funds from Workers’ Compensation was started in New York State in 1989. State and federal occupational disease surveillance programs should include standardized ethnic classifications and should provide data on Latino workers. In 1984 the collection of occupational disease data in the United States was described as “fragmented, unreliable and 70 years behind communicable disease surveillance” (Committee on Government Operations, 1984). Both occupational disease surveillance and communicable disease surveillance have advanced since 1984 but a large gap remains between data collection in these two areas. Principles of effective occupational health surveillance have been well summarized by Markowitz in Rom (1998), who wrote that “occupational health surveillance entails systematic monitoring of health events and exposures in working populations in order to prevent and control occupational hazards and associated diseases and injuries.” He went on to list four essential components of occupational health surveillance summarized by Markowitz in Rom 1998, who: gather information on cases of occupational diseases and injuries and on workplace exposures. distill and analyze the data. disseminate organized data to necessary parties, including workers, unions, employers, government agencies, and the public. intervene on the basis of data to alter the factors that produced these health events and hazards. (See “Primary Prevention Interventions” above). Consensus among authorities on occupational health surveillance holds that intervention must be an integral part of any surveillance program, in addition to the first three components mentioned above. It is clear from these principles that accessible occupational health clinical and educational services are necessary and prerequisite to establishment of an effective program of occupational health surveillance. Unionization, Worker Organization, Legislation, and Regulation of Workplace Ideally employers would provide healthy and safe working conditions without intervention from the outside. Some companies have identified worker health and safety as a priority and have in-house occupational medicine departments or have hired consultants to provide occupational health services. However, it is fairly common for employers not to provide healthy and safe working conditions. In these situations a union can facilitate the process of improving the health and safety conditions in the workplace. Organized workers are better able to avoid or reduce toxic and dangerous exposures in the workplace, with less vulnerability to being fired by an unscrupulous employer. Health and safety laws do not prevent an employer from firing a worker for becoming sick from their job,
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Safety is Seguridad: A Workshop Summary filing for Workers’ Compensation, requesting appropriate protective equipment, or for simply complaining about dangerous working conditions. The protections under the law that do exist are frequently circumvented when the employer asserts that the worker was terminated for economic or other reasons not related to health, and the burden of proof rests on the worker to demonstrate otherwise. Like other workers in the United States, only about one in six of Latino workers is a member of a union. Organizing Latino workers can be a crucial step in improving compliance with OSHA guidelines and bringing about safe and healthy working conditions, as we saw in the coated-fabric factory example. A strong union health and safety committee can often be effective in facilitating this process, especially when management cooperates and forms a labor and management health and safety committee. CONCLUSIONS The available evidence is inadequate to quantify the prevalence and incidence of occupational diseases and injuries in Latino working populations (although more and more sound estimates are becoming available) (Leigh et al., 1997) at national and state levels. The current estimates suggest that the overall risk of occupational diseases and injuries among Latino workers is beyond what should be expected. In spite of obvious inadequacies available evidence is certainly sufficient to justify primary prevention interventions in the occupations for which we have identified morbidity and mortality excesses. It also warrants a greatly accelerated investigation of the problem, specifically as it pertains to Latino workers and high-risk industries that employ them. Local epidemics of occupational diseases among Latino workers in particular industries have occurred and undoubtedly continue to occur. These epidemics are sometimes severe and could be readily observed if we looked for them. It is clear that primary prevention interventions are needed in the workplace, such as substitution of problem chemicals; process changes to address the sources of chemical and physical hazards; and other engineering interventions. In addition, secondary prevention interventions must also be conducted, including a rapid and substantial increase in clinical, preventive, and educational occupational health services accessible to Latino workers. Because most occupational diseases remain undiagnosed and unreported by the current medical system, improving the recognition, diagnosis, and reporting of occupational diseases by primary care, subspecialist, and occupational medicine providers will be critical. Recognition and clinical diagnosis of occupational diseases are prerequisite to adequate reporting, so improving access to clinical occupational health services will be a necessary step in this process. Although the focus of this chapter has been Latino workers, it is clear that in order to adequately address the problems of occupational disease and injury among Latino workers, any solution must address these problems among high-risk workers of all races and ethnicity. Addressing local epidemics haphazardly, if they happen to be discovered, will never be an adequate solution to this problem. A more humane, scientifically valid, and ultimately, cost-effective strategy for addressing this problem would be an integrated program of occupational health surveillance, accessible clinical occupational health services, careful epidemiological research, worker and health care provider education, collaboration with cooperative employers, unionization of Latino workers, legislative reform, and improved enforcement of regulatory standards.
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Representative terms from entire chapter: