Sunday, September 28, 2008

Mumbai Workshop: Occupational Health Issues in Sri Lanka

Dr. Hemantha Wickram of Sri Lanka's National Institute of Occupational Safety and Health (NIOSH) gave a presentation which outlined how the environment and occupational illness fall hand in hand. In school he studied carbon monoxide poisoning and found that underground parking lot attendants were having breathing troubles due to the poor ventilation engineering. He echoed what we had heard about unorganized sectors and how fragile those communities are in the developing world. Much of his talk was about the growing prevalence of HIV/AIDS among workers in his country. He spoke of "seafarers" and actually used the Austin Powers line about them going from port to port and spreading disease. He noted that since Sri Lanka has been developing and young people are coming from the rural areas, HIV is spreading rapidly in this community. The young migrants who come to Colombo are grouped together in group housing and females often turn to commercial sex work since they are not paid enough at their day-time jobs.

He talked about the use of personal protective gear which is of particular interest to me. I have been getting mixed answers about whether people are willing to wear masks in mines if given the option. In his studies, he found that workers do not use protective gear unless forced to by their employers. In Sri Lanka (as well as India) farmers spray pesticides without any protective equipment. In such hot weather it is very uncomfortable to wear protective gear so convincing someone to do so is nearly impossible.

After his presentation, I introduced myself and Dr. Wickram was very excited about an NGO from the United States working on occupational health education. We exchanged contact information and agreed to explore possible projects in Sri Lanka. I asked him whether or not he knows of any organizations trying to develop more comfortable protective gear. He said he did not know of such gear, but that he wanted to explore the idea.

Dr. Joshi, the organizer of the workshop, gave a summary speech. He told the story of a factory where different levels of exposure were divided into three categories and the workers were divided accordingly and wore appropriate protective gear for their area. The workers were frequently tested for their exposure levels. They found some young girls in the lowest exposure area who were recording extremely high levels of cadmium. They ordered a retest but found the same thing. The medical professionals dedicated a significant amount of research time into figuring out what was going on. Finally, on a trip to the plant, they noticed the girls biting their fingernails. This habit of nail biting was causing these girls to be exposed to a much higher level of cadmium. The story made a good point about the importance of actually visiting places of work to find what might be making workers sick.

Saturday, September 27, 2008

Mumbai Workshop: The Importance of Taking Complete Exposure Histories

After a long trip from Udaipur, we came to Mumbai for a workshop given to physicians from ESIC (A government department that provides healthcare and insurance to workers) The workshop focused on some of the big issues facing the health of workers in India today. The first presentation was from Dr. Arthur Frank, a Professor of Public Health Chair at Drexel University's Department of Environmental and Occupational Health.

He stressed the importance of taking complete exposure histories when diagnosing patients and examining workplace conditions. His talk was very impressive because he was able to root all that he was saying in his real-world experience. He listed symptoms and had the audience ask questions to determine the cause of work-related illnesses. He made each scenario seem like a riddle or an episode of CSI. I really enjoyed it.

He told an amazing story about a patient came in who was suffering from lead poisoning who actually worked for the EPA. After Dr. Frank went through his job habits, daily routine and hobbies he discovered this patient was a gun enthusiast who enjoyed going to shooting ranges. It turns out he was making his own lead bullets in an unventilated room which was making him sick. So it seems no matter how much awareness you have about the toxicity of a substance, you must remember the presence of such toxins in daily life.

In the United States children used to play in piles of asbestos outside of factories. In a country like India, where extreme growth in industry and construction is taking place, hazardous materials are everywhere. This made me think about the type of education our organization needs to provide to workers. We need them to fully understand what might make them sick so they can apply such lessons to situations outside the workplace.

Tuesday, September 23, 2008

Effective Cancer Education in Small Indian Towns: A Model for Occupational Health Education

Dr. Dave introduced me to many members of his staff and I was particularly struck by the work of Ms. Bhawana Jhaveri. She has been conducting cancer awareness programs in villages outside the city that have been very successful. The education programs go to schools and put on presentations about not smoking and early detection of common cancers. These presentations combine plays, flip-charts, folk music and drums in the street to attract attention. They have their own version of the "prom promise" where kids sign something promising not to smoke. I don't remember the prom promise being an effective deterrent, but she is still gathering data on the effectiveness of this type of program and I look forward to her results. She also runs workshops for medical professionals to teach them early detection methods. I am hopeful that we might work together in an effort to bring about occupational health education using the same methods. She seemed excited about working with us.

Ahmedabad: Community Asbestos Exposures

I took an overnight bus from Jodhpur to Ahmedabad to meet with Dr. SK Dave who worked for NIOH (National Institute of Occupational Health) in India from 1982 to 1999. He now works for the Oncology department at Gujarat Hospital. I have been emailing with him for more than a year and we have not accomplished much over email. I am amazed how much we were able to accomplish in a short meeting because we were face to face.

He says there is a lot of surface mining of rocks containing tremolite done by unorganized cottage industries in Dogrh. The rocks go into milling units and are crushed and sold. This material is dispatched for the manufacturing of non-pressure asbestos cement pipes. This piping is used in poor villages for irrigation. These pipes are poorly made and have leaks which contaminate ground water. They would be better off using iron or copper but these materials are very costly.

Dr. Dave works at one of the best cancer hospitals and research institutes in India. Their oncology department has been trying to create a cancer registry with some difficulty. He tried to create a database but finds doctors in the villages are just not willing to use a computer. Then he dropped a notebook off with village doctors but they were still not reporting much of anything. When he added a financial incentive to report (10 rupees per reported case) he was able to get some responsiveness. I asked him how he was able to ensure that these were accurate given the incentive to over-report. He said he does follow-ups with patients and looks for unusual patterns but that some over-reporting was a problem at first. He said recently he has been getting patients referred to him from southern Rajasthan with mesothelioma and pleural effusion who have not been working in the mills or mines. Most of these community exposures have not been explainable.

While my organization is not willing to jump into a study that will simply show the dangers of asbestos (we already know asbestos is dangerous), I would be willing to contribute to a study of victims of community exposure to asbestos. He said I should think about going around southern Rajasthan next time I am in India and making sure local doctors know what to look for so that proper patients are referred and documented. I am interested in knowing as much about community exposures in Rajasthan as possible and Dr. Dave is going to assist with this project.

Sunday, September 21, 2008

Sandstone Mining in Keru: "An Open Jail"

Dr. SM Mohnot arranged for a visit to a sandstone mining area 15 km outside of Jodhpur. The area is famous for the high quality sandstone slabs that are crushed there using hydraulic drilling, dynamite and hammers. In recent years, this area has become increasingly dependent on mining as the amount of annual rainfall has declined. We drove down the narrow roads of the town of Sursagar en route to a collection of mines in Keru.

I was initially worried about how the employer would react to our visit, but to my surprise he wasn't even there. Our guide informed us that he only comes to the mine around 3 days a week. This helps explain why he might not be concerned about the dust levels. Apparently the miners don't need much supervision as a certain output is required and monitoring this output is enough to run the mine.

We Interviewed a worker (through the help of a translator) named Sultan Khan, from a village 150 km away. His wife and children are in that village, but he spends most of the year here. He is 35 and works 8-10 hours per day and makes 100-110 Rs each day. During the rainy season, if there is no drought, he goes home and works in agriculture, but since droughts are common he must supplement his agricultural income by working in mines. When asked about silicosis he had never heard of it.

The mining process seems arduous and none of the workers were using face masks or protective clothing. The area was very hot and the workers were blanketed in a thick layer of dust. The drilling is also incredibly noisy from the drills. I can't imagine working in these conditions. The workers all seemed to be in a daze. I was there for just a short period of time but I felt nauseous from the dust for awhile after my visit. On the way back, our guide described the situation as an "open jail." I think it might be worse than that.

Tuesday, September 16, 2008

Silent Deaths: Tuberculosis and Silicosis Surrounding Jodhpur

We arrived in Jodhpur last night and woke up early to meet Doctor S.M. Mohnot, Director of the Mine and Labor Protection Campaign. Apparently 95% of mining here is done by small privately owned groups. None of the mines surrounding Jodhpur are in compliance with federal laws requiring best practices and safety provisions for employees. In fact there is at least one death in these mine every day. Silicosis and tuberculosis are two of the largest issues the Mine and Labor Protection Campaign is focusing on today.

Sandstone mines surround Jodhpur. There are 8,000 to 9,000 of these mines owned by the private sector which have been able to sustain a workforce due to droughts in the villages 20-200 km away leaving agricultural workers unemployed and hungry. Mining has contributed to the amount of land that cannot be used for agriculture. The natural resources in the villages near Jodhpur have been phenomenally damaged and this has left many villagers in financial crises. Mine owners often use this crisis to their advantage to exploit their employees. Miners are forced to work in temperatures up to 48C and as low as 0C. They also do not earn enough to buy nutritious food for themselves and their families. They are extremely malnourished. Employers routinely give addictive substances like alcohol and opiates to their workers to keep them working for 12 hour shifts and keep them coming back to work. Employers also give large loans to employees in financial crisis and exploit them this way. Dr. Mohnot called it enslaving people through hypnosis.

India is a large country with a huge population where, according to Dr. Mohnot, the value of life is way too low. The majority of workers coming from rural areas are illiterate and undereducated. It is difficult to spread awareness of hazardous working conditions to them. He values the idea of empowering workers to take these issues on themselves and says that amongst these groups there are sensible and worthy leaders to be found to organize them and disseminate important information about rules and regulations that are not being followed.

To understand the plight of these employees socioeconomic, environment, and political climate in the region all must be taken into account. Economic needs should be balanced with ecology, local fruits, local milk, good water and pollution control.

I asked about the education of medical professionals and he agreed with Dr. Joshi's analysis that most physicians do not diagnose patients with occupational illnesses because they can't recognize them. Most silicosis patients are treated for tuberculosis. He said they needed a standardized method to diagnose silicosis which they currently do not have.

I asked him about my plan to promote materials coming from places of work that are using best practices and creating safe work environments. He said the European Commission started something like this but did not follow through. The Netherlands for some times was only importing stone that was mined without child labor and was largely effective at reducing the number of children employed. But this needs to be a collaborative effort.

I like Dr. Mohnot. His determination is inspiring. He views mining in Jodhpur as a human rights violation which should not be ignored. I also noticed him turning off lights and fans in rooms that were not being used and encouraging people to walk rather than use their cars. He booked us at a hotel close to his office and took us out to a modestly priced lunch. He clearly understands the value of little things. He has noticed the effect climate change has had on the desert villagers of Rajasthan and makes changes in his own life accordingly. I plan to spend more time with him visiting nearby mines and villages this week.

Monday, September 8, 2008

Jaipur Foot

Today we visited a successful NGO formed in 1975 in Jaipur known as Jaipur Foot. This organization helps amputees rehabilitate themselves and re-renter the workforce. Many of these amputees are victims of workplace injury. They create a prosthetic limb from plaster and rubber for less than $35 which is realistic looking and quite functional. The patients themselves are treated free of charge and all services are provided from donated funds. Jaipur Foot provides not only artificial limbs, but also calipers, crutches, ambulatory aids like wheelchairs, and hand paddled tricycles.

The processes used by the organization were very advanced and it seemed they make a huge effort to train patients in some sort of trade so they would have a way to make money when they left the center. The organization has chapters all over the world and has been treating people in places like Manila, Nairobi, Nigeria, Rwanda, Uganda, Honduras, and Panama, with the help of Rotary International, the World Rehabilitation Fund and other organizations. They also provide training to local medical technicians so that they can continue working when Jaipur Foot technicians return to India.

We were given a tour of the organization site in SMS hospital. There are many stages to the process including collecting a mold, filling the mold with plaster of paris, and using this mold to create a rubber foot and leg. The patients we met seemed happy and were enjoying lunch provided by Jaipur Foot. Most organizations do charge a small fee for such services and an employee at the organization said they are sometimes criticized for providing all of this for free. Apparently, there is a feeling among NGOs in India that it is important to charge a small fee for charitable services to be taken seriously. But the patients who come to Jaipur foot usually have no money at all and therefore a service fee model would not work for them.

Some Welcome Constructive Criticism from a Jaipur Doctor

Last night we had dinner with Dr. Sidharth Consul, an opthamologist from Jaipur and his lovely wife Renu, a general practitioner. He was very interested and very opinionated about the mission of our organization. He seems to think that employees and employers know the dangers they face in the workplace and that the education we aim to provide will not be as helpful as we think. When I asked him what he thought we should focus on, he said that reaching out to employers and making them understand the financial consequences of unsafe workplaces would be more effective.

He mentioned how easily stone cutters damage their eyes, contracting keratitis. Still, none of these workers wear protective goggles even with this knowledge.

My position is that with more complicated occupational diseases like pneumoconiosis, education is more important. However, Dr. Consul seemed aware of these issues and still thinks my efforts should be aimed at employers. He also said it would take a lot of work to pressure these employers since he thinks they simply don't care.

He told me a story about a chicken slaughterhouse that dumped waste into surrounding neighborhoods and swimming pools making people very sick. When Dr. Consul approached the owner of the slaughterhouse, he was shocked to learn that not only was the owner aware he was making people sick, he knew there was a cheap alternative that would take care of this waste. He simply did not care. Dr. Consul is worried that if regulations are not enforced by the law people will never care about safety and the impact their work has on the environment.

I suggested our organization might reward organizations who followed safety regulations and best practices by promoting them overseas as places to import goods from. He thought this was a good idea. I will be talking to more doctors and businessmen here about this business model to see if it might actually work.

Friday, September 5, 2008

Jaipur Rotary Club: an Attempt to Reach Employers

We were invited to attend a meeting of Jaipur's oldest Rotary Club to speak about our organization. I didn't really know what to expect so I prepared a few notes and thought I would adjust my speech based on the other speakers who were to go before me. The first 30 minutes, which was spent having tea and some traditional Indian snacks, was productive. I went around and introduced myself to the various members who turned out to be local businessmen, many who work in industries I am trying to reach. They were receptive when originally introduced to me but the phrase "occupational health" is never very exciting to anyone. They mostly wanted to talk about San Francisco and their kids who were in America. I humored them and talked about San Francisco, but gave them a brochure and made it a point to at least get in a few words beyond "occupational health education." We all sat down and the meeting began with recognition of teachers day and some opening ceremony in Hindi. But to my surprise the entire meeting was in Hindi. Damn you Rosetta Stone for being so expensive at airport kiosks! Why have I not learned much Hindi!? Well, two long speeches went on and I didn't have the slightest idea what they were saying. The only thing I gathered was that they were too long and that the audience wanted to get out of there. So when my turn came I was brief and frank.

I basically said that such a group of talented businessmen should understand that keeping their workers safe and healthy was a good investment for them and that I could help in this regard. I said that there are simple measures employers can take to mitigate occupational health hazards and that these measures were much cheaper than the workers compensation and retraining of new employees they would surely face if they left their workers in hazardous conditions. I think it went well because the president of the club thanked me for being brief and several businessmen gave me their cards and asked me to contact them.

Thursday, September 4, 2008

The Delightful Mathurs Welcome us Into Their Home

We are staying with a family in Jaipur called the Mathurs who live near Collectorate Circle. They are four siblings in their fifties living together a charming period house that belonged to their parents. The Mathurs include Dr. Beena Mathur "Delilah", the eldest sister. who teaches in the University of Rajasthan. She lives with her husband who is a retired Colonel from the Indian Army. Delilah and her husband live her two younger sisters - Dr Reena Mathur & Dr Meena Mathur, both Professors in the University of Rajasthan and a brother who is a freelance media professional. Also living there is the charming Anjana, from Nepal, who helps manage their house while we they all away working. They call it “Tara’s Place” in memory of their mother. It isn’t a Guest House with a sign outside the door but a live in accommodation with the residents – mainly for the benefit of visiting professors, scholars and students. Staying with a family is making it so we can really get an understanding of local politics and how NGO's work in India. Delilah's husband is a member of the international rotary club and has told us about several local projects they are involved in. They have been vaccinating children in poor areas around the city in an effort to eradicate the disease. He also works with the local "Jaipur Foot" organization that helps amputees obtain prosthetics. There is also a leper colony near the Kanak Brindavan Temple. People in India often put family members out who contract leprosy. The organization near Kanak Brindavan Temple rehabilitates them and teaches them useful trades so that when they are able to leave they will have something to keep them off the streets.

Can India afford not to Have more Occupational Health Physicians?

Dr. Gupta and Dr. Joshi mentioned how few physicians were trained in occupational health and the need for foreign medical professionals for training. Both Dr. Gupta and Dr. Joshi had been trained in the UK and US and hoped to eventually have training occupational health training for physicians in India. They were not speaking of a years of training but a short course or some lectures. They said if their hospital advertised lots of doctors would come. I think that if we had one of the members of our medical advisory board fly to Delhi to give a lecture doctors would be willing to pay to attend. The money we gathered from these fees could be used to start an educational project for workers sponsored by Dr. Joshi and his staff at the Center for Occupational and Environmental Health. When I suggested this to Dr. Gupta he thought is was a really good idea. He agreed that doctors would take the lecture more seriously if they had to pay an admission fee and that this would be a good way to collect funds for his efforts. This is exactly the kind of thing I think our organization should be doing: empowering people to take action within their own communities.

Wednesday, September 3, 2008

Regulations Improve: Industry Keeps Running

On Friday August 29, Dr. Gupta offered to take us to an old stone crushing site in Delhi. We met him at the hospital at 10 AM and off we went in a lovely air conditioned car. As we drove I was able to pick Dr. Gupta's brain a little more which was awesome. We talked about unorganized work sectors where employees were exposed to high levels of silica. He spoke about the importance of awareness of hazards in the workplace . A huge challenge he faces is illiteracy within these communities.

When asked what he thought the best solution to these problems was he focused on alleviation of poverty. He spoke about the drawbacks of free trade and how technology from the developed world comes to India without the transfer of education to the workforce. As these industries move into emerging economies we must ensure workers are aware of the hazards within the workplace.

While trade unions are an option for the unorganized workforce, there are only a few trade unions in India such as the CITU (Communist Indian Trade Union) and the SITU (Socialist Indian Trade Union). These trade unions are very political and have vested interests that are not necessarily best for the workers. These unions are also largely influenced by employers.

Dr. Gupta told us an interesting story about a trade union that worked with a factory that manufactured radios and televisions using old vacuum tube technology. The trade union was giving workers a glass of milk every day and saying that this would help with metal poisoning. In fact, milk does not help with metal poisoning. Dr. TK Joshi told them this and said that if they were going to distribute something an apple would at least be more nutritious and helpful to the workers. When he tried to work with the employees to get this change done the workers just preferred the extra five Indian Rupees (around 13 cents) a day the apple would cost and consequently both programs were canceled. Often when workers are made to understand the hazards they are working with they just want more money rather than safer conditions.

Dr. Gupta told us of his appointment to a panel of five experts to look into possible mercury poisoning at a plant. He found gross negligence there. The expert panel could not prove that the illnesses the workers were facing were the direct cause of mercury. Dr. Gupta fought that they could not prove that the mercury poisoning DID NOT come from mercury poisoning. This discussion was of particular interest to me given my experience with expert witnesses in toxic tort cases.

We arrived at the old stone crushing mine to find a very impoverished community. Dr. Gupta showed us around and it was amazing to be right next to something I had read so much about and seen so many pictures of. The people in the community seemed very interested in our presence and Dr. Gupta was even approached by someone who recognized him from his work in the field there.

Tuesday, September 2, 2008

COEH Visit: Worker Education in India

It's our first day in India and we met Dr. TK Joshi in Delhi who invited us to the Center for Occupational and Environmental Health (COEH) at GB Pant Hospital near Connaught Place in the center of Delhi. This is a government agency which focuses on occupational health issues and is staffed by occupational health physicians. We met him and his associates, including Dr. Neeraj Gupta, and learned about the challenges India faces in occupational health education.

We were able to spend a significant amount of time with the doctors and were able to ask all sorts of questions. I felt I should have been more prepared but I have been studying this subject for quite a few years and sometimes there are just too many things to ask. I just wanted them to speak freely and after we spoke in detail about our intentions they came alive. I wanted to know what they felt were the immediate needs of the medical community and the challenges they faced as occupational health professionals.

In 1992 the Supreme court ruled that in Delhi workers must be kept safe "by any means possible," and unlike some other states, Delhi regulated it's industries well. This caused most stone crushing industries to move 70 km outside the city, to the state of Haryana. The 1948 Factories Act does require industries in India to follow guidelines to keep their workers safe but it is up to the state to enforce these rules. Dr. Joshi plans to open a clinic in Badapur soon. It seems wherever industry faces regulation that makes work more expensive, they seem to find somewhere else to go. This reinforces my feeling that education of the workforce is the answer to these problems.

It also reminded me of some previous recommendations that I received back home in San Francisco. Christa Robertson RN, a friend of mine and a member our Medical Advisory Board gave me a recommendation based on the success she had experienced in public health education. When she read my initial proposal back in July she mentioned giving workers a short quiz before educational programs and giving them the same quiz after to measure our success. I was very happy to hear that Dr. Joshi and Dr. Gupta had been doing this sort of thing and wanted to continue doing so. They said there was a need for these quizes to be catered for every industry, I agreed. I expressed the need for these types of measurements to give funders an idea of how successful our programs were and they seemed to agree. I want to fund projects they carry out with oversight, but I want them to understand that I trust them.

I told them of my disappointment with the way litigation had been a burden on workers in the United States who had been made sick from asbestos exposure. They agreed that the purpose of our projects should focus on the persuasion of employers not prosecution. Unfortunately, they do not get enough support from the labor department. It is difficult for them to enter places of work. They find it frustrating that only one occupational health professional is nominated to the labor department and the rest of the nominees are engineers. This professional is only answerable to the labor department. The labor department does not do field activities or implement the law. They mostly work with big reputable multinational institutions.

I was extremely encouraged that both doctors are primarily interested in working with the unorganized sector. These are small employers who have run cottage industries and rarely pay attention to laws and regulations. Most of these workers are illiterate and very poor. They are the ones who would benefit most from educational programs aimed at workers.

Dr. Gupta kept saying, "You are answerable to your own self, at the end of the day you want to contribute to something good."

He cautioned us to look at individuals and evaluate them based on their goals.

"Every individual has his own initiatives," he said.

They spoke of the power of pamphlets and brochures and hope some day to make a documentary that is in English, Hindi, and local language. This would help with education and awareness. They agreed that smoking cessation was extremely important.

Monday, September 1, 2008

Pneumeconiosis in India: A Preventable Catastrophe

The International Work-to-Live Project is embarking on a five week journey to India to investigate areas of interest for our first project, Pneumoconiosis in India: a Preventable Catastrophe. The team includes myself and the Project's Chief Operations Officer, Jonathan Zuk.

I have been aware of a lack of occupational health and safety standards in emerging economies and have been studying related topics for over two years. After working with several American pulmonologists concerning issues of asbestos exposure in the US I have become keenly aware of what educational and awareness programs worked and which ones did not. Scaring people and putting them out of work is not a sustainable way to help people. Earlier this year I started this organization as a way to apply this experience to emerging economies sucha as India, Turkey, and China in the hope that these countries do not have similar experiences. Last month, our organization became officially tax-exempt and hosted our first fundraiser in Northern Virginia.

Jonathan and I are touring Northwest India to see where this money might best be spent. We will be visiting the states of Delhi, Rajasthan, Gujarat, and Maharasthra. Thus far we have scheduled meetings with occupational health professionals in many Indian cities. My goal is to find good people who understand the mission of our organization and can help us carry out it's goals.