The environmental and occupational safety of residential and work places have an enormous impact on people’s health. Public health measures implemented during the 20th century have improved people’s living and working environments, resulting in increased longevity. However, dangerous occupations and harmful environmental exposures continue to be major contributors to disparities in health.^1,2,3 Health-care providers also often ignore these important risk factors for disease.^4,5 In addition, it is important to consider how individual susceptibility and social vulnerability may influence the health risks related to specific hazards (see Box 25-1).⁶

This chapter reviews adverse health issues attributable to environmental hazards in the workplace and at home, highlighting their disproportionate effect on vulnerable populations and presents practical approaches for preventive and therapeutic interventions to improve screening and care of patients with work and environmentally related illnesses.

UNEMPLOYMENT AND HEALTH

Unemployment is an important risk factor for the ill health faced by poor and minority populations. Unemployed workers have higher rates of morbidity and mortality caused by multiple diseases, most prominently cardiovascular disease and suicide.^7,8,9,10 It has been hypothesized that recessionary economic cycles, characterized by unemployment and decreased income, may have profound negative effects on population health, especially for those on the lower rungs of the socioeconomic ladder.¹¹ While some of the indirect effects of recession may improve the health of the population (e.g., people cut back on driving and there are fewer accidents), people who are directly affected by loss of their homes or jobs have deteriorating health. Men who lose their jobs have higher mortality for a decade¹² and are more likely to develop a new health condition than their employed counterparts. Undergoing foreclosure is also often accompanied by declines in health.¹³ Unskilled and semiskilled workers in cyclic industries are among the earliest to become unemployed, and remain so for the longest periods. Economic downturns have a negative impact on mental health. Increased morbidity and mortality may result from the stress of unemployment, compounded by a lack of access to health-care. Workers who enter long-term unemployment following a structural change in the economy (e.g., after the introduction of a new technology such as automated harvesting machinery) often have inadequate education or native language proficiency to obtain new jobs in different sectors when the economy recovers. Low-wage, migrant, minority, recent immigrant, female, and older workers are particularly vulnerable.

RACE-BASED DISCRIMINATION IN THE WORKPLACE

Race-based discrimination at work can lead to increased stress and poor health.^14,15 Several studies suggest that stress from racial discrimination may be associated with mental health disorders, hypertension, coronary artery disease, and poorer pregnancy outcomes.¹⁵ In a cross-sectional observational study of 356 African Americans from Atlanta, the likelihood of a physician diagnosis of hypertension increased significantly in patients who perceived high levels of stress from race-based discrimination.¹⁴

HOUSING AND THE BUILT ENVIRONMENT

As a majority of our time is spent indoors, mostly at home, inadequate housing quality has important health implications, exposing occupants to the following hazardous conditions: poor insulation, indoor air pollution (smoke from biomass stoves; nitrogen and sulfur dioxides from gas appliances), inadequate water and sanitation, cockroach and rodent infestation, dust mites, hypothermia and hyperthermia, dampness, mold, dangerous levels of lead in contaminated dust, residential soil, fire hazards, deteriorating structural integrity, and lead-based paint.^16,17

The majority of global urban growth is occurring in low- and middle-income countries (LMIC), with up to 40% of growth occurring in urban slum housing.¹⁸ In the United States alone, 10.7 million families live in substandard housing (i.e., deteriorating houses or apartments) and Latino and African-American families are disproportionately represented. These housing hazards have been associated with a variety of adverse health outcomes.^19,20 A cross-sectional analysis found that neighborhoods with a high “broken windows” index (i.e., the sum of percentages of homes with major structural damage or boarded-up vacant housing units; the percentage of streets with garbage, abandoned cars, or graffiti; and number of building code violations in public high schools) also had higher rates of premature death from all causes and from several specific causes (e.g., diabetes, homicide, suicide) and higher rates of sexually transmitted diseases.^21,22

Overcrowding and poor-quality housing also have been associated with poor mental health, developmental delay, heart disease, and even short stature.¹⁶ Unfortunately, the most vulnerable populations (infants, children, elderly, and chronically ill) are those who spend the most time indoors and are often socially isolated, making them less able to avoid these hazards.

Despite declines in the prevalence of lead poisoning in the United States, children aged 18–36 months living in poor and inner-city communities continue to be at high risk for lead poisoning. Additionally, lead continues to be used in many other parts of the world in paint, gasoline, ceramics and pottery, cans, and countless other products.²³ Lead poisoning can result in neurologic damage, reduced IQ, hyperactivity, increased aggression, and learning disabilities.

Exposure to excessive heat during summer heat waves is another housing-quality problem that primarily affects elderly persons living in older homes with inadequate ventilation and cooling. The health effects from extreme heat events are likely to become more frequent due to climate change.²⁴ Distributing electric fans, providing air conditioning in specific areas of apartment buildings, and transporting the elderly to air-conditioned areas can reduce heat-related mortality.²⁵ Community action plans that involve public service workers to keep an eye on socially isolated elderly individuals during heat waves have proved effective.²⁶ More information can be found in the World Health Organization’s Heat-Health Action Plan ().

The CDC defines the built environment as “all of the physical parts of where we live and work (e.g., homes, buildings, streets, open spaces, and infrastructure).”²⁷ Characteristics of the built environment, such as low walk/bike-ability, lack of safe access to green space and recreation areas, and low neighborhood availability of healthy food options, promote poor nutrition and a sedentary lifestyle that increase the risk of obesity.

Lack of access to safe drinking water and improved sanitation, either in homes or publicly accessible locations, also remains a widespread problem in LMICs resulting in tremendous morbidity and mortality from infectious disease transmission and chemical contamination (e.g., arsenic, nitrates, and perchlorates) of drinking water.

NEIGHBORHOODS AND VIOLENCE

A neglected and disorderly physical environment increases the risk of crime. Homicide is the fourth leading cause of preventable deaths in the United States. Latino and African-American men aged 18–50 years are disproportionately represented in these deaths.²⁸ Economic deprivation, social disorganization, and acculturation are independent risk factors for homicide mortality among Mexicans and African Americans. Residents of public housing surrounded by green space had a stronger sense of community and reported using less violent ways of dealing with domestic conflicts.²⁹ Community and/or hospital-based violence prevention programs can reduce the risk of violence perpetration, violent victimization, and promote nonviolent self-efficacy.^30,31,32

AIR POLLUTION AND HEALTH

While many higher income countries have witnessed improvements in ambient air quality in the wake of effective clean air regulation, the benefits remain unevenly distributed. More than 80% of the residents of poor urban centers in the United States are ethnic and racial minorities. These populations are chronically subjected to poor air quality because they live in close proximity to transportation facilities (bus depots, trucking stations, rail yards, and ports), high-volume roadways, waste treatment stations, power plants, toxic waste sites, refineries, and industrial facilities. Additionally, industrialization and urbanization in some LMICs have resulted in dramatic deterioration in air quality, particularly in the mega-cities of East and Southeast Asia.

Common urban air pollutants include nitrogen dioxide (NO₂), ozone, carbon monoxide, particulate matter, sulfur dioxide, and lead (the United States Environmental Protection Agency [EPA] regulated criteria pollutants³³), as well as toxic air contaminants.³⁴ These are strongly associated with excess cardiopulmonary mortality, increased health-care use, asthma exacerbations and possibly incident asthma, decreased lung function, increased respiratory symptoms, increased airway reactivity, and lung inflammation.^34,35 Other pollutants, the so-called toxic air contaminants (e.g., benzene or perchloroethylene) are known to be associated with cancer and reproductive abnormalities.³⁴

Because lung growth continues into early adulthood, children are especially vulnerable to respiratory tract toxicity from urban air pollution. A longitudinal study of children from southern California reported that exposure to high levels of air pollutants was associated with decreased growth of lung function over an 8-year period and clinically significant decreased forced expiratory volume in 1 second (FEV₁) by the age of 18 years.³⁶ A number of studies have also shown adverse effects of urban air pollution on birth outcomes. For example, a prospective study of minority pregnant women in New York City reported that exposure to high levels of urban air pollutants (specifically, polycyclic aromatic hydrocarbons) was associated with decreased birth weight and head circumference among African-American newborns.³⁷ Finally, asthma morbidity and mortality rates are highest among African Americans, especially children, living in urban areas and are associated with high levels of ambient pollution.³⁸

In LMICs, approximately 3 billion people continue to use solid fuels for cooking or heating (including coal, wood, crop residues, and dung).³⁹ Smoke exposure from solid fuel use has been associated with cardiovascular disease (Box 25-2), chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and cataracts; this may be an important risk factor to consider in immigrants from countries that continue to rely on these fuels.⁴⁰

FATALITIES IN THE WORKPLACE

Ethnic and racial minorities are disproportionately represented in occupations with higher risks for fatal injuries.^41,42,43,44 Foreign-born workers account for 42% of the growth of the US labor force and their workplace fatality rate is on the rise, whereas the national workplace fatality rate has declined.⁴³ Latinos and younger workers suffer the highest rates of workplace fatalities and the majority worked in the following five occupations: (1) transportation and material moving; (2) handlers, equipment cleaners, helpers, and laborers; (3) farming, forestry, and fishing; (4) construction trades; and (5) security. In all five industries, foreign-born workers experienced higher fatality rates than their native-born coworkers.⁴⁵ The most common fatal events were highway motor vehicle incidents (22%), violence (17% including homicide and suicide), and falls to a lower level (13%).⁴⁶ Reasons for increased mortality of foreign-born workers include higher rate of employment in hazardous jobs, longer hours, piece-work incentives, and less training.

In the United States, workplaces associated with the highest rates of homicides are taxicab establishments, liquor stores, gas stations, detective or protective services, justice or public safety facilities, and grocery and jewelry stores.⁴⁷ Other risk factors associated with homicides include male gender, working early or late hours, working in high-crime neighborhoods, and occupations engaged in the exchange of money or valuables. Finally, elderly workers and adolescents suffer from workplace homicides at a higher rate than others.⁴⁸ Elderly workers likely are less able to defend themselves when assaulted and are at increased risk of dying from an assault. Younger workers who are foreign born have higher rates of being killed at work.

NONFATAL OCCUPATIONAL INJURIES

Laborers or unskilled construction workers are more likely to suffer from serious injuries requiring hospitalizations than are more-skilled workers.⁴¹ Urban dwelling workers, both men and women, who are injured on the job tend to be young and unskilled. Their injuries commonly affect the musculoskeletal system and have an impact on their immediate ability to work and their long-term health.⁴²

MIGRANT FARM WORK AND HEALTH

The agricultural industry is another inherently dangerous industry. It employs less than 2% of the US workforce but is responsible for 10% of workplace fatalities.⁴⁹ The agricultural industry employs approximately 4 million migrant and seasonal farm workers. A migrant farm worker establishes a temporary home in order to do seasonal agricultural work, while a seasonal worker does not migrate.⁵⁰ Migrant workers and their families are among the most underserved and understudied populations in the United States. Nearly all migrant and seasonal farm workers are ethnic and racial minorities; 90% are Latino and the remainder African American or non-Latino Caribbean.⁵⁰

Migrant workers are at risk for various work-related illnesses, including pesticide-related illnesses, musculoskeletal strains/sprains, traumatic injuries, noninfectious respiratory diseases, dermatitis, infectious disease, cancer, eye problems, and mental health problems.⁴⁷ The burden of these problems is exacerbated by minimal access to health care. The children of migrant farm workers may also be expected to work in the fields after school, be exposed to harsh working conditions, and have an increased rate of dropping out of high school.

SUBSTANDARD HOUSING FOR MIGRANTS