Guest Commentary

Women's Work and Health: Interactions and Implications
By Linda Hawes Clever, MD, MACP

History of Women's Work and Health
In 1993, a California study on women asked, "Safe at Work?" and concluded, "No."¹ What has changed since then? Indeed, what has changed since 1700, when Bernardino Ramazzini described infections in health care workers and lung disease in laundresses?² Midwives no longer contract syphilis of the hands, but health care workers contract diseases from other bloodborne pathogens. Pulmonary fibrosis no longer develops in laundresses from lye, but clothes handlers incur repetitive strain injuries from ironing. Lamentably, in the last 300 years, we have made few advances in understanding the causes of work-related disorders. Ramazzini² favored the noxious nature of menses, wet clothing, and overheated blood. Today, we still can only guess about the reproductive toxicity of most chemicals. Worse, we know almost nothing about the toxicity of combinations of chemicals. The lack of good long-term studies is not as much a testimony to failures of science but rather to our society's indifference to workers and consequent lack of research funding in occupational health and safety. Hunches, allegations, and retrospective studies cannot prove cause and effect. Without hard data, effective preventive policies are not adopted. That premise is as true now as it was in 1700.

Despite limitations, we can work with the information we have. We can also advocate for increasing work-related research and for healthier workplaces for women and men. We must emphasize prevention, because occupational illness and injury can resist diagnosis and treatment and can ruin lives. In this article, I will give an overview of occupational health concerns and will also answer occupational health questions frequently asked by practicing clinicians.

Current Status of Women's Work and Health
Although women and men work in the same jobs, their distribution within the work force differs. About 80% of workers in office settings and almost 90% of workers in health care settings are women.³ Life situations can be more trying and complex for women. They earn about three quarters as much for working the same number of hours as men do.⁴ Career "glass ceilings" and sexual harassment still exist. Women also tend to have remarkably different caregiving responsibilities for children and elders: five out of six single parents are women, and many of these women also work outside the home.⁵ At home, where many older Americans require attention, spouses are the most common caregivers (38%), followed by daughters (19%); sons provide 8% of elder care.⁵ Life, work, frustrations (and opportunities and joys) all interact with health. What can we do for women workers, knowing their pressing multidimensional responsibilities?

The Clinician's Role--First Take a Good Work History
We can start by obtaining thorough work histories from our patients. "Work" may be paid, unpaid, or both. Work may involve exposures to toxic materials (correction fluid in offices, latex in hospitals, cleaning agents at home); circumstances (tensions and deadlines everywhere); air contamination ("sick building syndrome" in offices, waste anesthetic gases in hospitals, sidestream smoke at home). A good work history gathers accurate information about exposure to chemicals or to other agents and use of video display terminals (VDTs) or other equipment requiring repeated or extreme movements. A job title is not enough: some women painters work on bridges, not canvases. A woman who works as a painter might be exposed to lead and have to wear a self-contained breathing apparatus. Indeed, about 9% of the 8.1 million construction workers in the United States are women.⁶ A job "analysis" is better. A job analysis lists agents, work hours, lifting and overtime requirements, and protective gear. A Material Safety Data Sheet (MSDS) gives even more information: chemicals, acute and chronic damage, and antidotes. Every company in the United States is required to have a MSDS for each chemical it uses or manufactures. This document should be available to the worker and to clinicians, although there is always danger that a worker's inquiry about work safety can lead to harassment or job termination.

Ask About Job Satisfaction and Life Circumstances
Taking a work history involves more than asking about job exposures and requirements. Asking about work also includes asking about job circumstances and satisfaction. A colleague of mine once opined that the leading cause of death of women at work was boredom, but, in fact, homicide is the leading cause of death of women at work. More than 7000 persons die each year at work in the United States.⁷ Of women who die at work, 42% are murdered compared with 11% of men.⁸ Most killings occur in retail and service sectors. Contrary to myth, personal disputes or problems with coworkers or former coworkers account for less than 10% of murders at work.⁸ Nonfatal assaults of both women and men workers are also of concern. Health care patients, primarily in nursing homes and hospitals, account for the largest proportion of assailants (45%).⁸ Attacks by nonpatients occur in hotels, motels, and all-night markets, where low-paid, front-line service workers are at risk. If actual death at work is uncommon, strain from repetitious, emotionally exhausting, all-consuming work (often overseen by video cameras or computers staffed by distant supervisors) can be deadening.

Remember to Ask About Work at Home and Home Life
In addition to gathering information about a woman's paid work, learning about her work at home and work habits is essential as well. This knowledge includes use of risky substances such as oven cleaners, garden pesticides, solvents, or any hazardous agents used in paid work. Ergonomics at home can be hazardous. Repetitive strain can occur from improperly installed VDTs or from lifting babies or parents. The effects of medications or drug abuse, including alcohol and tobacco, can add to work exposure and increase the severity and incidence of devastating illnesses such as cirrhosis and mesothelioma.

Difficulty at the workplace and difficulty at home, or both, can result in more frequent and, often, more frustrating health-seeking visits. Violence, harassment, and exposure to toxic chemicals or circumstances can occur anywhere. Effective, efficient care takes this work/home mosaic into account. Finding all the pieces by asking pertinent questions can solve the puzzle. One way to explore these interwoven forces is to ask, "How are you bearing up?" and "Has anyone hurt, frightened, or harassed you lately?" These questions asked at every visit apply to patients' work as well as to their domestic lives.

Occupational Health Referrals
Work issues are on patients' minds. When health care professionals ask about work, patients usually feel more comfortable knowing they are in caring, thorough hands. Nonetheless, some courage is required to ask questions about work because so few of us have been trained in that arena. Courage is especially required to ask questions when we may not know what to do with the answers. But after a few visits (an entire occupational health history does not need to be taken at the first interview), we may have concerns about a patient's work at home and on the job. Where can we turn for help? The Permanente Medical Group has a cadre of first-rate occupational health specialists available for consultation or referral. Local health departments or universities may have occupational and environmental medicine departments. Material Safety Data Sheets can be crucial. One of the best resources for general information is the National Institute of Occupational Safety and Health's (NIOSH) fax line (1-800-35NIOSH). Web sites can be helpful as well, such as the Centers for Disease Control and Prevention (http://www.cdc.gov) and NIOSH (http://www.cdc.gov.niosh).

Answering Questions Clinicians Ask About Work and Health
Now that some occupational health terrain has been mapped, let us move to the front lines and list questions frequently asked by clinicians:

What Can I Do about Repetitive Strain Injury?
Repetitive strain injury can happen to you and your family as well as to your patients and office staff. VDTs are a major source of problems. Do not dismiss complaints. The most important thing to do is to adjust every workplace and playplace to fit each person: "'A' is for Adjustability." That policy, along with early intervention and appropriate treatment, is the best answer to repetitive strain injury. Exercise, nonsteroidal anti-inflammatory agents (even aspirin), and splints can help, along with early referral to rehabilitation.

What Are the Most Common Problems of Health Care Workers? What Can I Do about These Problems?
Although violence is a headline matter, more commonplace damage to health care staff occurs in nursing homes, where lost time injuries from overexertion are four times the national rate.⁹ Most reported problems are musculoskeletal, especially back injuries, just as with other workers. Appropriate staffing, equipment, and training can decrease injuries. A "lift team" can be beneficial as well. At one medical center during a nine-month period, not one nurse (nor lift team member) was injured when the team was on duty whereas several per month were injured before. The worst fear is needle sticks. Not every device has the same risk. Hollow-bore, blood-filled sharps are the worst. Safer devices must be tested and purchased. Equipment that cannot be "sabotaged" is the safest. That is, the safest equipment requires no activation step and no relearning but rather reinforcement of usual techniques. No size fits all, and, again, adjustability is most important. Safer sharps disposal is also key.

The most common and invidious problems for health care workers are emotional burdens. Emotions do not go away spontaneously. Exhaustion, grief, depression, conflicts with colleagues and family members, discouragement, competition, the "hurry sickness"--all these are signs of pressure and problems that need addressing, not burying. Advising your colleague-patients to get in touch with values and to take some time for themselves is essential. Even taking a deep breath every so often or taking a sip of water so that one eventually has to take time off to go to the restroom are little activities that can improve a day. Asking revealing questions is important. Psychiatrist Dr Michael F Myers asks, "Where am I most indispensable?" (oral communication, December 1998).^a The answer can lead to important insights and decisions for our patients and for ourselves.

What Travel Tips Can I Provide?
Do not recommend or take melatonin for jet lag. Dosage and long-term effects are untested.

Travel agents may have a conflict of interest about giving health precautions. The CDC's free International Traveler's Information Line (877-394-8747) gives up-to-date, accurate information about infections and vaccinations. The CDC's Yellow Book is available by calling the same number. The US Department of State's Office of American Citizens' Services gives timely information on street violence, terrorism, insurrections, and other dangers.

How Can I Decide Whether or Not to Give a Person Permission to Work?
From the ethical standpoint, communication must be honest and restricted. A clinician cannot give an excuse for a patient if the patient has not been seen. Say instead, "The patient reports an inability to work."

Do not give a diagnosis to an employer unless it is clearly work-related or the worker gives permission. No employee "permission" is uncoerced, however. Therefore, do not mention hypertension, cancer, emotional problems, or any other medical or psychiatric diagnoses that can be misinterpreted by underinformed human resources or management personnel.

A single clinician cannot know all the fine points of work capability. If there is a doubt whether a person has the necessary stamina for work after myocardial infarction or because of muscle incoordination associated with multiple sclerosis, for example, referral to rehabilitation/occupational therapy for job simulation can be illuminating.

Research Implications
Work is a source of money, respect, self worth, status--and dangers. Work exposure and responsibilities may interfere with diagnosis and treatment. Toxic substances and circumstances such as excess physical demands, excess heat, and excess hours and responsibilities can affect health. These observations lead to the following research goals:

• Learn interactions of chemicals, circumstances, and life.
• Define actual workloads that women carry, including home and job.
• Discover ways to prevent problems, including the best kinds of social support for those who have demanding lives.

Summary
Life, work, and health interact. We must recognize this in our own lives as well as in our patients' lives.

Become active on behalf of your patients:

• Urge research.
• Visit workplaces.
• Urge adoption of social policies that help women who work 100 hours per week. This means advocating for additional help for child care and elder care.
• Inform patients about workplace risks just as you warn about smoking and alcohol.

Be active on your own behalf:

• Analyze your own workplace for safety and health risks.
• Set limits.
• Ask, "Am I asking too much of my friends and family?
• Check your "energy bucket." If frustration, frenzy, anger, resentment, or a sense of being dismissed empty your energy bucket, refill it by reexamining values, aligning them with your workdays, and making time for yourself and loved ones. The goals include regaining personal and professional satisfaction as well as maintaining relationships and a sense of humor.

Conclusion
The worksite cannot be separated from home life; health depends on both. Environmental hazards and stresses, including violence, are encountered at home and on the job. Physicians therefore need to add a few questions to their routine visit questions:

• Tell me about your work (for pay, at home, your hobbies, in your community) and how you feel about it.
• Can you get me a copy of the Material Safety Data Sheets of the chemicals to which you are exposed?
• Has anyone hurt, frightened, or harassed you lately?

Physicians need to be compassionate while asking these questions. Author-statesman John Gardner has said, "Be kind, for everyone you meet is fighting a hard battle" (unpublished manuscript, September 2000).^b William Osler said, "Do the kind thing, and do it first." Women's work is difficult and can be satisfying--whether paid, unpaid, or both. Our challenge is to extend our professional interests and clinical investigation to all of the interactions of women's work, lives, and health.

^a Department of Psychiatry, St Paul's Hospital, Vancouver, British Columbia, Canada.
^b School of Education, Stanford University, Stanford, California.

1. Zones JSP, principal researcher. Women's occupational health and safety in California: safe at work? [Sacramento, CA?] California Elected Women's Association for Education and Research. California Women's Health Project, 1993.
2. Ramazzini B. Diseases of Workers. Translated from the Latin text of 1713 by WC Wright. New York: Hafner, 1964.
3. United States. Bureau of the Census. Statistical Abstract of the United States, 1999. 119th ed. Washington DC: For sale by the Supt. of Docs., USGPO, 1999. Table No. 675. Employed Civilians, by Occupation, Sex, Race, and Hispanic Origin, 1983 and 1998, p. 424-6.
4. Highlights of women's earnings in 1999. [Washington, DC]: US Dept of Labor, Bureau of Labor Statistics, [2000]. p. 1.
5. United States Department of Labor. Futurework: Trends and Challenges for Work in the 21st Century. 1999.
6. Welch LS, Goldenhar LM, Hunting KL. Women in construction: occupational health and working conditions. J Am Med Womens Assoc 2000 Spring;55(2):89-92.
7. National census of fatal occupational injuries, 1999. Washinton, DC: US Dept of Labor, Bureau of Statistics, [2000]. On the World Wide Web: http://www.bls.gov/specialrequests/ocwc/oshwc/cfoi/cfnr0006.pdf. Accessed Sept 18, 2000.
8. Violence in the workplace: risk factors and prevention strategies. Cincinnati, OH: United States Department of Health and Human Services, National Institute of Occupational Safety and Health, Division of Safety Research; [1996]. On the World Wide Web: http://www.cdc.gov/niosh/violcont.html. Accessed Sept 18, 2000.
9. Stellman JM. Women workers: the social construction of a special population. Occup Med 1999 Jul-Sep;14(3):559-80.

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