Introduction: Linking Work and Health in 3D Jobs

In Baluchistan, the largest province of Pakistan, there are six enormous and highly profitable coal fields where underground coal mining is carried out by a beleaguered workforce of some sixty thousand miners. Mining in the area dates to the 1850s, to the period of British colonial rule. Today, most coal mine owners and leaseholders are powerful people who live far away from the mines in major cities like Karachi and Lahore. These workers endure “debt bondage and human rights abuses, an absence of basic health and safety measures, and brutal working and living conditions” (Baloch and Ellis-Petersen 2020). At Mach coal fields, located 60 km from the provincial capital, mineworkers commonly live nearby the mines. The threats of underground explosions, methane gas poisoning, suffocation, and mine wall collapse are ever present and few workers have not been touched by mine-related injuries and fatalities among family members. Explains Luqman Shakir, a 24-year-old forced into mine work because of poverty and lack of education: “Twenty people that I know of have died underground… People often die because of a mine collapse and it takes us 18, sometimes 24, hours to take them out because there is no machinery to remove the collapse; we are on our own… When we pull them out, often their bodies are so mangled they cannot even be recognised. Every time I go down the mine, in the back of my mind I always know there is a possibility that I might not come back up” (quoted in Baloch and Ellis-Petersen 2020). Research on the health of coal miners in Baluchistan indicates that because of a high concentration of coal dust mineworkers experience frequent headaches, throat, nose, and eye irritation, drowsiness, shortness of breath, nausea, pneumoconiosis, tuberculosis, chronic obstructive bronchitis, early aging, neuropsychiatric impairment and heart problems. Waste coal water and slurry is disposed of in nearby areas that contaminate drinking water causing gastrointestinal conditions and diarrhea among miners.

The conditions and structuring of work—whether paid or unpaid—has been shown to have a significant impact on the health of workers, their families, and their communities, not just in Baluchistan but around the world. While the health of workers has long been of some interest in our discipline, and certainly has gained greater attention in the 21^st century, the interrelationship of work and health remains an understudied topic among anthropologists. There is, asserts Flynn (2019), a “need for a more holistic and nuanced perspective on work and its impact on population health.” Moreover, the pathways directly linking the organization of work in society, the living and working conditions of laborers, the realities of “everyday life,” and health outcomes remains undertheorized. In an effort to begin addressing these deficits, a number of anthropologists have begun to adopt a biosocial syndemics model in the study of worker health (Gonzalez et al. 2023; Kline 2013; Singer 2023; Unterberger 2013). Syndemic theory calls for new ways of thinking about health by focusing simultaneously on both internal body interactions and external social factors in a holistic manner. Colleagues and I developed the concept of syndemics during the 1990s based on research with street injection drug users, individuals who were mostly unemployed, or at best episodically employed in off-the-books jobs, including work in the illicit drug industry. In developing this concept, we sought to capture two levels of complexity that we were finding in the health profiles of our interlocutors: 1) a clustering and suggested adverse interaction of comorbid diseases and related health conditions (e.g., HIV and the trauma of violence in the case of illicit drug injectors); and 2) the role of pernicious social conditions and hierarchical societal relationships (e.g., poverty, stigma) in driving disease clustering and interaction, as well as in creating overall physical vulnerability. This set of factors, acting in unison, contributed to enduring suffering, a heavy disease burden, and high rate of mortality among the individuals enrolled in our research.

To date, the literature on occupational syndemics affirms the conclusion of Abrams (2001:37) that “if we are to understand the history of occupational health, it must be viewed in the context of the labor-capital relationship: work-related disease is socially produced and is, therefore, pre-ventable…” Despite promising initial efforts, as yet the full potential of a syndemics framework for deconstructing the complexities of occupational health under neoliberal capitalism remains unrealized. My goal in this essay is to suggest as a preliminary step a framework to guide the study of health among people who work in what have been called 3D jobs, i.e., “dirty, dangerous, and difficult.” These jobs involve risky and often physically arduous manual labor with prolonged periods of repetitive motion, types of labor that are stigmatized or socially devalued and underpaid, and often are undertaken—for lack of better alternatives—by people from socially marginalized groups. 

A Conceptual Model of Occupational Syndemics

Conceptual models are simplified abstractions used to convey the key elements and field of relationships in complex real world processes. Thus, the proposed conceptual model of occupational syndemics introduced below seeks to draw on the holistic tradition in anthropology to suggest the array of likely factors in need of examination in understanding the local making of worker health in context across time, place, and occupation.

Model of Occupational Syndemics

Harm and Elite Culture

Social class has an important influence on attitudes about oneself and one’s relations with and outlook on others in society. In a series of innovative experiments Paul Piff and colleagues (Piff 2014), for example, found that compared to individuals from lower social classes, upper-class individuals have a heightened sense of entitlement as well as an “inflated view of the self, a self-aggrandizing and dominant orientation toward others, increased grandiosity, and heightened feelings of uniqueness and individualism.” Moreover, they exhibit a reduced sensitivity to others’ suffering. In that this appears to be a shared characteristic of the wealthy globally, characterized by a distinctive set of tastes, values, and lifestyles, I refer to it heuristically as the elite culture of entitlement/deservingness. A notable feature of this “culture,” suggests Noam Chomsky (2013), is that the elite act as if they are free to do as they please in the world because Earth and its varied resources are their rightful estate. This characteristic is seen, for example, in the fact that the ways of life and business practices of the wealthiest individuals in the world are primary drivers of disruptive climate and environmental change. This pattern reflects the ‘throwaway ethic’ in contemporary capitalism, a term that describes the excessive production of disposable items, viewing the environment as a limitless wastebin for the polluting products and byproducts of manufacture, and treatment of members of the working class as expendable. Notes St. Martin-Lowry (quoted in Robinson 2023) “When you view people as a commodity, it is only natural to treat them as such. People are seen as interchangeable, and you can always hire another set of hands when you need to.”

Central to the profit-driven capitalist approach to structuring social relations of work is the exploitation of socially marked differences, including class, gender, race/ethnicity,

nationality, and migration status.  This strategy, termed racial capitalism by its critics, produces profit by ensuring a vulnerable supply of underpaid workers through a racialized division of labor and related practices. It also, as an unintended but commonly ignored (or actively hidden) consequence, produces a profoundly negative impact on worker health and safety.

Maintenance of the blatant injustices of racial capitalism is vigorously enforced through physical, symbolic, and structural violence on and beyond the job site.  Using both state and hired forces, physical violence is a specific form of aggression that involves coercion, injury, and death. Symbolic violence, involves insidious, less-than-physical, reinforcement of inequality through language, the media, and other communication forms while masking underlying power relations. In the work domain, managers and other organizational agents work to ensure that “processes of exploitation are suitably disguised” enabling “powerful groups in society to acquire … distinct economic and social advantages” (Dick and Nadin 2011). Structural violence, a well-known concept in anthropology, references embedded, institutionalized, and normalized forms of violence, such as racism, sexism, and classism, through which the powerful inflict harm on subordinated groups by preventing them from meeting their basic needs and aspirations. Collectively, these intwined forms of violence constitute what Pierce (1976) called “crimes of the powerful.” Their occurrence and frequency reflects the mutually beneficial relationship commonly found between state/public actors (e.g., heads of state, legislators) and private actors (primarily large corporations).

The Health Costs of Occupational Violence

For workers, the crimes of the powerful constitute what might be termed “occupational violence,” the intersecting social relations of production and supportive wider fields of power that lead to avoidable impairment of the meeting of the need for safe, healthy, non-alienating, and fully compensated work. The physical harms of occupational violence are seen in the specific arrays of work-related injuries and health problems recorded among workers in 3D employment. Typical is the case of Anasuddin Mallick, a 25 year old man who left his village to find work in a leather tannery in the city in Tamil Nadu, India. He aspired to make enough money in a chemical intense tanning factory to send money home to his family. One month into his new job his hand was crushed in a leather processing machine. He was sent back to his village, uncompensated and unable to work (Price and Price 2017). The emotional harm caused directly and indirectly by occupational violence is experienced as chronic stress, socioeconomic disadvantage, and an awareness of individual expendability. The notion of occupational violence as a researchable topic draws from the concept of environmental violence with specific expression in the workplace and work-related community.

Notably, Marcantonio and Fuentes (2023) illustrate environmental violence with a work-related example: industrial gold mining by foreign mining companies like London-based African Minerals Limited in the environmentally protected northeast sector of Sierra Leone. Resource extraction there is facilitated through physical violence (firing on striking workers), structural violence (state/private sector collusion to permit mining), and symbolic violence (labeling local residents as backward and expendable because they are rural farmers). Overall, commercial mining in Sierra Leone characterized by human rights abuses including hazardous working conditions, mistreatment on the job, and the use of physical violence against workers. Moreover, due to toxic releases from the mines, workers and their families experience increased rates of skin rashes, headaches, confusion, lethargy, and malaise, and attribute a perceived increase in fetal abnormalities, miscarriages, early unexplainable mortality, and other negative health outcomes to the degradations of mining. While research on corporate gold mining in Sierra Leone is limited, research on the health of gold miners around the world finds decreased life expectancy, increased frequency of cancer, and increased frequency of pulmonary tuberculosis, silicosis, pleural diseases, as well as heightened rates of diseases of the blood, skin, and musculoskeletal system. Across the world from Sierra Leone, Cravey (1998) describes the occupational violence faced by recruited female workers in the foreign-owned assembly plants along the U.S. border. These labor migrants work long hours (10 ½ hours/day), often without breaks, doing repetitive motion tasks, using dangerous and antiquated equipment, for far less money than would be paid for the same work just across the border in the U.S. Additionally, they are subject to sexual harassment from male supervisors and are exposed to carcinogenic toxins on the job and in work-associated crowded dormitories.

Over time, working under conditions of occupation violence produces chronic occupational stress that is experienced physiological and emotionally as suffering from memory and concentration problems, insomnia, body aches, constant fatigue, irritability and mood swings, anxiety, the sense of being emotionally drained, and feelings of hopelessness. The development of occupational stress has been linked to a number of work-related conditions, including repetitive and monotonous tasks; lack of control over work assignments; an uncomfortable physical environment (e.g., heat, noise, odor); mistreatment by managers; limited job satisfaction; and lack of job insecurity, all features of 3D jobs. Among miners, for example, studies show that working environments are “relatively poor, labor intensity is high, working hours are long, and the social status of … workers is low. [This] working environment can easily contribute to varying degrees of occupational stress that affect the quality of life of employees” (Liu et al. 2016). 3D workers also face socioeconomic disadvantage and often fall into the category of “the working poor.” Research indicates that the working poor “experience huge stress levels and it has been proved that they have a lower average length of life” (Rimnacova and Kajanova 2019). Adding to the burden of occupational stress is painful worker awareness of being a disposable commodity that is assigned to a “not quite human” life status. This experience is seen, for example, in the words of a South African mineworker who was quickly laid off of his job after he developed symptoms of work-related silicosis: “We used to do blasting twice a day and were working just minutes afterwards in the dust. The mines just used us up and threw us away” (quoted in Burke 2016). Adds a migrant farmworker in California in protest over the way workers are routinely mistreated “No somos personas desechables” (We are not disposable people) (quoted in Dwyer 2020). 

The Making of Occupational Syndemics

In affected worker populations, the interaction of the noted set of adverse biological, psychological, environmental, and social threats they endure contributes to the development of occupational syndemics. This array includes noxious exposures, depending on the kind of work, to: 1) pesticides and other biochemicals in what have been called extreme environments (chemically intensive corporate agricultural sites in a context of unprecedented global heating) (Saxton 2015); 2) noxious fumes like coal dust, crushed silica, and diesel exhaust, 3) toxic substances like mercury, cadmium, asbestos, and tannery chemicals like hydrogen sulfide and ammonium hydrogen sulfide; 4) infectious diseases like tuberculosis, COVID-19, and HIV; and 5) risks of musculoskeletal damage and other physical injury. Moreover, due to the vicissitudes of occupational violence, the bodies of 3D workers suffer from chronic stress and enduring exposure to stress-related hormones (CRH, cortisol, catecholamines and thyroid hormone). Prolonged exposure to these chemical messengers—which evolved to ready the body to face acute challenges—pushes the body to constantly work harder and literally weathers the cells of the heart, the arteries, and the neuroendocrine systems while deregulating both innate and adaptive immune response (Geronimus 2023). This deleterious process of aging and breakdown creates or enhances physical vulnerability to disease in a population.

Chronically stressed, socioeconomically distressed, marginalized populations, and physically vulnerable groups are subject to a concentration of multiple diseases and health conditions. Multimorbid disease clustering (the co-presence of two or more serious medical conditions in a population) can occur by chance; however, some disease clusters occur at higher than chance levels. Higher than chance disease clusters have been linked to cumulative structural disadvantage and inequality. For example, research by Pais (2014) on race/ethnicity and health in the U.S. found that “one-third of blacks (28%) in the United States experience some form of impairment during their prime working years compared with 18.8% of whites.” Further, racial/ethnic differences in childhood mediate this difference in health patterning “through the indirect pathway of occupational attainment and through the direct pathway of early-life exposure to health-adverse environments.” Research on workers at 58 corporations in Australia (Holden et al. 2011) identified six multimorbid clusters in the sample: 1) arthritis, osteoporosis, other chronic pain, bladder problems, and irritable bowel; factor; 2) asthma, chronic obstructive pulmonary disease, and allergies; 3) back/neck pain, migraine, other chronic pain, and arthritis; 4) high blood pressure, high cholesterol, obesity, diabetes, and fatigue; 5) cardiovascular disease, diabetes, fatigue, high blood pressure, high cholesterol, and arthritis; and irritable bowel, ulcer, heartburn, and other chronic pain. While this study did not attempt to link identified clusters to specific jobs or working conditions, this is suggested by other research.

Disease clustering creates the opportunity for adverse disease interactions. Notes Fitzmaurice (2000), when two explanatory variables are considered together, outcomes may simply be the “sum of the parts” (known as individual effects). Or, if the joint effect is significantly larger (or smaller) than the “sum of the parts,” there is an “interaction” among the explanatory variables.” In diseases, this can occur across multiple pathways and mechanisms, including: 1) diseases/conditions that weaken the effectiveness of components of the body’s immune system or cell repair processes; 2) diseases that damage organs and tissues facilitating the onset of another diseases/conditions; and 3) diseases that disrupt body cellular signaling causing a downgrading of cell functioning, increasing vulnerability to and the impact of another disease. Syndemics theory “posits that … intertwined health problems produce a stronger and more intense overall adverse health outcome than if each of the conditions were experienced separately” (Slagboom et al. 2021).

Moving forward

The combination of multiple biological and social factors underlying disease and multimorbidity and the way that these factors interact produces particular local syndemics. Framing research using the syndemics model provides a direction for the recognized need to move toward a biosocial approach in the anthropology of worker health and well-being. Moreover, syndemics can be used to formulate both public health and clinical approaches for improving worker health, and comprehensive responses to the drivers of health inequities.

References

Abrams, Herbert 2001 A Short History of Occupational Health. Journal of Public Health Policy 22(1): 34-80. https://doi.org/10.2307/3343553

Baloch, Shah and Ellis-Petersen, Hannah 2020 “Coal workers are orphans’: The children and slaves mining in Pakistan. The Guardian https://www.theguardian.com/global-development/2020/feb/19/coal-workers-are-orphans-the-children-and-slaves-mining-pakistans-coal

Chomsky, Noam 2013 Who owns the Earth? TruthOut www.truth-out. org/opinion/item/17402-who-owns-the-earth.

Cravey, Altha 1998 Women and work in Mexico’s Maquiladoras. Lanham, MA: Roman and Littlefield.

Dick, Penny and Nadin, Sara 2011 Exploiting the exploited: The psychological contract, workplace domination and symbolic violence. Culture and Organization 17(4): 293-311. DOI: 10.1080/14759551.2011.590306

Dwyer, Dustin 2020 "We are not disposable people." Farmworkers speak out on conditions that have led to outbreaks. Michigan NPR https://www.michiganradio.org/health/2020-07-01/we-are-not-disposable-people-farmworkers-speak-out-on-conditions-that-have-led-to-outbreaks

Fitzmaurice, Garrett 2000 The Meaning of Interaction. Nutrition 16(4) 313-314.

Flynn, Michael 2018 I’m/migration, work, and health: Anthropology and the occupational health of Labor Im/migrants. Anthropology of work review 39 (2): 116-123.

Flynn, Michael 2019 Towards a Biosocial Approach to Occupational Safety and Health. NIOSH Science Blog https://blogs.cdc.gov/niosh-science-blog/2019/03/08/biosocial-osh/

Geronimus, Arline 2023 Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society.Boston: Little Brown.

González, Rubio, Manuel, María del Mar Jiménez-Lasserrotte, María Idoia Ugarte-Gurrutxaga, Karim El Marbouhe El Faqyr, José Granero-Molina, Cayetano Fernández-Sola, and Fernando Jesús Plaza del Pino. 2023. Experiences of the Migrant Farmworkers during the Syndemic Due to COVID-19 in Spain. Social Sciences12: 273. https:// doi.org/10.3390/socsci12050273

Holden, Libby, Scuffham, Paul, Hilton Michael, Muspratt, Alexander, Ng, Shu-Kay and Whitefor, Harveyn 2011 Patterns of multimorbidity in working Australians. Population Health Metrics 9: 15 http://www.pophealthmetrics.com/content/9/1/15

Kline, N. (2013). “There’s no where I can go to get help, and I have tooth pain right now”: The oral health syndemic among migrant farmworkers in Florida. Annals of Anthropological Practice, 36(2), 3870401. https://anthrosource.onlinelibrary.wiley.com/doi/abs/10.1111/napa.12010

Liu, L., Wu, H. and Yang, Y. 2016 The mediating effect of psychological capital of underground miners on the relationship between occupational stress and anxiety symptoms. China Health Statistics 33: 209–211, 214.

Marcantonio, Richard and Fuentes, Augustin 2023 Environmental violence: A tool for planetary health research. Lancet Planet Health 2023; 7: e859–e867.

Pais, J. 2014 Cumulative structural disadvantage and racial health disparities: the pathways of childhood socioeconomic influence. Demography 51(5): 1729-53. doi: 10.1007/s13524-014-0330-9. 

Pearce, F. 1976 The crimes of the powerful: Marxism, crime and deviance. London, England: Pluto Press.

Piff, Paul 2014 Wealth and the inflated self. Personality and Social Psychology Bulletin 40(1):  34-43. 

Rimnacova, Zuzana and Kajanova, Alen 2019 Stress and the working poor. Human Affairs 29: 87-94.

Robinson, Bryan 2023 The Return Of The Disposable Work Culture And 4 Steps To Restore Employee Loyalty. Forbes https://www.forbes.com/sites/bryanrobinson/2023/07/08/the-return-of-the-disposable-work-culture-and-4-steps-to-restore-employee-loyalty/?sh=57c30653c829

Singer, M. 2023. Syndemics of the sea: Adverse disease interactions and the stressors of fisher livelihoods. Fish and Fisheries, https://onlinelibrary.wiley.com/doi/abs/10.1111/faf.12803

Slagboom, M., Reis, R., Tsai, A., Büchner, F., van Dijk, A. & Mathilde, C. (2021). Psychological distress, cardiometabolic diseases and musculoskeletal pain: A cross-sectional, population-based study of syndemic ill health in a Dutch fishing village. Journal of Global Health 11, 04029.

Unterberger, Alayne 2018 “No one cares if you can’t work”: Injured and disabled Mexican-origin works in transnational life course perspective. Anthropology of work review, 2018, Vol.39 (2), p.105-115

Author Bio

Merrill Singer is an Emeritus Professor at the University of Connecticut. His research over the last 50 years, rooted in a critical medical anthropology theoretical framework, examines the making of disease in political economic context.

[email protected]