Scavengers cleaning latrines in India and pickers working in the vast warehouses of online retail businesses have something in common: firsthand experience of the kind of low-status work said to contribute to inequalities in health.
In his third ABC Boyer Lecture, epidemiologist Sir Michael Marmot argued that a divide is emerging in society, between busy, interesting jobs that give life meaning, and jobs that harm the body and damage the soul.
Studies have found the stress of a work environment that is high in demand and low in control increases risk of mental illness and of coronary heart disease by about 50 per cent.
Other stresses characteristic of low-status jobs — such as an imbalance between effort and reward, organisational injustice, social isolation, shift work and job insecurity — have also been proven to damage health.
In his speech, Sir Michael told the stories of Alan and Lalta: two people who have done the kind of work that contributes to inequalities in health.
Alan’s life as a picker
Before he was fired for “collecting three penalty points”, Alan worked as a picker in an online retailer’s warehouse.
“On arrival for his shift, Alan was handed what was in effect his controller and conscience: a hand-held electronic device that directed him to Row X to pick up item Y and put it in his trolley; then to Row P to pick up item Q, and so on,” Sir Michael said.
“When his trolley contained about 250 kg his device would direct Alan to the packers. Then he’d be off again for another load.
“His target was 110 large items an hour, more for smaller items, two a minute. That was the job, for nine and half hours, plus the hour of breaks.”
The electronic device was also used to give feedback on his performance, so he could be monitored and warned if he did not keep up the pace.
“If he fell too far behind he would incur half a penalty point; more, a whole point,” Sir Michael said.
“When, on one shift, he went off sick, he incurred another penalty point.”
There was no time for Alan to talk to other employees. In fact he rarely spoke to anyone except his line manager, whose job it was to warn him about his failure to meet targets.
One night he used a pedometer, and realised he had clocked up 18 kilometres of walking over the shift.
“Added to the heavy physical demands, Alan’s work was characterised by high demand with no control over the work task, by high effort and little reward, by social isolation at work, by job insecurity, by organisational injustice, and by shift work — each of which has been shown to damage health,” Sir Michael said.
“It was as if his employers had taken everything we know about damaging aspects of work, concentrated them in a syringe and injected them into Alan.”
Lalta’s life as a scavenger
Sir Michael compares Alan’s experience to that of Lalta, who lived in the city of Alwar, in Rajasthan, India.
“Her occupation, and that of a million or so others like her in India, was to clean human excrement out of dry latrines by hand, pile it in a reed basket, carry it on her head to a dumping place and deposit it,” he says.
“Can you imagine a line of work more foul? Lalta couldn’t either. As she said: ‘All I missed was my dignity … I felt like the dirt I carried on my head.'”
At the age of 17, Lalta married into a family of Dalits, the caste of Indians who make up about one sixth of India’s population, and traditionally perform the most demeaning work.
“Most of the latrines built in India in the 20th century were of the dry type, largely because of water shortage,” Sir Michael says.
“The scavengers had to reach in through a tunnel and retrieve the human waste by hand.
“The problem with work like Lalta’s is a double burden: as well as the physical and biological hazards, there is the gross lack of dignity, the threat to self-worth, the appalling stress of such an occupation.
“Lalta felt there was no way out. She was told this was her fate. Not that there was calm acceptance of it: ‘There was no happiness in our lives. It actually had no meaning. All the time it was either people’s filth on the head or its thought in the heart.'”
Jobs can make you sick, but so can joblessness
While work can be bad for health if it deprives people of control over their lives or does not pay adequately, Sir Michael pointed out that unemployment has its own health risks.
He referenced the indignados of Spain, protesters on the streets of Madrid who are among the roughly 40 per cent of youth in the country who are unemployed.
“They are angry with good reason. Society’s implied promise to them has been broken,” Sir Michael said.
“Not usually given to hyperbole, I have described this youth unemployment as a public health time bomb.
“Unemployment is bad for health and it blights lives. Young people who leave school for the scrapheap are in danger of never getting the habit of work — potentially, they face a lifetime on the margin. Bad work may be bad for health; unemployment may be worse.
“Unemployment is particularly bad for mental health. Some of our politicians claim that unemployment is a lifestyle choice. If so, it is an odd one as it puts people at increased risk of depression and suicide.”
Studies have confirmed this connection. Figures examined by Oxford University’s David Stuckler show a correlation between a rise in a country’s unemployment rate and a rise in that country’s suicide rate.
What can be done?
There is another ingredient that can disrupt the link between unemployment and suicide, Sir Michael said.
“The size of the effect varied according to how generous a country was in its spending on social protection, which included unemployment benefits, active labour market programmes, family support and health care,” Sir Michael says.
“The conclusion was straightforward: unemployment damages mental health so severely that it can even lead to suicide, but government policies can make a difference.”
Sir Michael has also been heartened by Lalta’s story.
After a non-governmental organisation installed low-cost, safe sanitation systems to replace the dry latrines she worked to clean, she was able to retrain as a beautician.
“From a heap of humiliation to the heights of self-respect and self-confidence, I believe life has turned out miraculously for the good,” he quoted Lalta as saying.
“When I hear people in rich countries lament appalling working or living conditions with no apparent way out,” he continued, “I remind them of Lalta and people like her in demeaning work all over the world, and the power of group action and vision to transform people’s lives.
“It is worth bearing in mind, as we examine the evidence on work and health, that if the working conditions of India’s scavengers can be improved by concerted action, all working conditions can be improved wherever we find them.”