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Stress and health

'Excessive stress can effectively destroy the quality of life for the individual, his or her family and for society as a whole. It has become as dangerous as pollution to modern society' (Clive Purkis, Director of the European Foundation for the Improvement of Living and Working Conditions, 1993.)

In this part we look at the effects on health of stress at work. We present evidence to dispel the idea that stress is exclusively a condition suffered by middle-aged male managers and we offer some ideas for counteracting the kinds of work organisation which lead inevitably to work-related stress.

Financial facts

Lets start with some bald economic statistics. The total annual cost to the Country of work-related accidents and ill health is estimated by the HSE to be between 11 billion and 16 billion (Davies and Teasdale 1994). 7 billion of this total is accounted for by workforce stress (Rochez and Scoggins 1993). According to the HSE's research, almost 10 per cent of the entire workforce suffers from work-related stress at any one time (Davies and Teasdale 1994) and 80 million working days are lost each year due to mental illness (CBI 1993). However, a Europe-wide survey by the European Commission in 1991/2 suggests that this figure may be a gross underestimate. The survey found that almost one in two European employees suffer from occupational stress (European Commission 1992).

These shocking statistics demonstrate that moral, social and ethical considerations are failing to persuade employers to carry out their duty to provide safe systems of work for their employees. Perhaps the HSE's recent advice to employers that accidents and ill health "will hurt your balance sheet" will have more impact. Fear of spiralling employee health care costs and compensation, argues Professor Cary Cooper, a prominent researcher into causes of occupational stress, is the reason why levels of stress-related illnesses are declining in the US, but not in the UK where the tax payer, via the National Health Service, picks up the bill (Cooper 1986).

It will be interesting to see if future statistics bear out the findings of a recent Confederation of British Industry (CBI) Survey that 60 per cent of companies now design jobs and training to alleviate stress (CBI 1993). It would be encouraging to believe that UK employers shared CBI Director General Howard Davies' view that "A company's workforce is its most important asset. An individual's state of health, both mental and physical, is critical to the quality of their work." (Hazards Winter 1993/4). Unfortunately, the evidence from hazards centres and occupational health projects around the Country is that far from valuing their workforce, the majority of employers see them as an expendable commodity, to be exploited for maximum productivity, then discarded when ill health threatens to incapacitate them.

Of course, to victims of work-related ill health and their families the costs go far beyond financial costs and include the loss in overall quality of life and general well-being resulting from the suffering associated with illness, the worry and grief caused to their families and friends, and the effects of long-term or permanent incapacity.

Defining stress

Stress is the term often used to describe distress, fatigue and feelings of not being able to cope. There are numerous academic definitions (including engineering, physiological and psychological approaches) which focus on the relationship between individuals and their environment, but we have chosen the following definition to encompass the most important elements:

Symptoms of work-related stress

Defining a clear link between occupational causes, and the resulting symptoms is much harder for a condition such as stress than is it for a disease such as mesothelioma (which is only caused by exposure to asbestos). Because many of the symptoms of stress are generalised - such as increased anxiety, or irritability - it is easy for them to be ascribed to a characteristic of the worker, rather than to a condition of the work. As we will show, however, there is mounting scientific and medical evidence that certain types of work and work organisation do have a measurable, and verifiable impact on the health of workers.

The range of symptoms includes the following:

Physical symptoms

headaches and migraine colds and other respiratory infections asthma raised cholesterol levels increased blood pressure ulcers digestive tract disorders heart disease increased risk of cancer thyroid disorders diabetes menstrual disorders possible effects on pregnancy sleepless nights lethargy karoshi (sudden death from overwork)

Mental health symptoms

irritability depression increased risk of suicide withdrawal anxiety low self esteem 'burn out' post-traumatic stress disorder

Psychosocial symptoms

heavy drinking increased use of drugs smoking eating disorders increased sickness absence increased accident rates breakdown of relationships

Some degree of stress is a normal part of life and provides part of the stimulus to learn and grow, without having an adverse effect on health. When stress is intense, continuous or repeated - as is often the case with occupational stress - ill-health can result.

The experience of stress can affect the way individuals think, feel and behave, and can also cause physiological changes. Many of the short and long term illnesses caused by stress can be accounted for by the physiological changes that take place when the body is placed under stress.

Effect of stress on the body

Information on the physiological effects of stress could take up a book on its own. In this section we concentrate on well-documented effects which have been clearly linked to occupational causes.

There are four physiological systems which are particularly vulnerable to stress (Cox 1993): the cardiovascular system (heart and blood circulation system); the endocrine system (the hormone system); the gastro-intestinal system (digestive system) and the immune system (the body's defence system).

Fight or flight

The body reacts to stress in the first instance by invoking the flight or fight response. This reaction was very useful to our ancestors - enabling a quick response to threatening situations. But in today's workplace it is often impossible for people to fight the stress or run away.

During the response, the hormone adrenalin is released, increasing heart rate, blood pressure and sweat production. There is an increase in muscle tension, and breathing becomes rapid and shallow. The hormone cortisol is also released, which in turn stimulates the release of body fuels like glucose, fatty acids and amino acids. Intense, prolonged or repeated provocation of this response by having, for example, constantly to meet unrealistic deadlines, causes increased wear and tear on the body, and contributes to what have been called 'diseases of adaptation'.

Research in rats suggests that prolonged exposure to adrenaline and cortisol can accelerate the aging of brain cells and lead to impairment of learning and memory (Consumer Currents August 1991). [check original report].

Heart and blood circulation system

If stress is continuous, permanent high blood pressure or hypertension can develop. This hypertension can damage blood vessels walls and disturb kidney function. It can lead to bursting of blood vessels in the brain (a stroke) and around the heart (a heart attack or coronary), both of which can be fatal.

When stress is continuous, the body has no chance to reabsorb the body fuels released as part of the stress response. Fatty acids build up in the blood stream and fat is deposited in blood vessel walls, causing a narrowing of arteries. The arteries can harden, blood clots form, the supply of oxygen to heart muscle is reduced and pain, known as angina can result. When the oxygen supply to heart muscle is severely restricted, heart attacks, and death, can result.

A recent review of scientific research on this issue reported that 12 out of 14 studies showed that there was a clear link between occupational stress and heart disease (Landsbergis 1993). Furthermore, it was estimated that 23 per cent of heart disease (and 150,000 deaths per year) in the US could potentially be prevented if the stress levels in jobs with the worst stress levels were reduced to the average of other occupations. The studies also showed that more women and black workers faced higher levels of stress than their male, white, counterparts.

In Japan, sudden death from a heart attack or stroke brought on by overwork is known as karoshi. Karoshi first emerged as a problem in the 1970s, coinciding with cuts in jobs and a resulting increase in individuals' workloads. Many Japanese bank employees work an average day of 12 hours. As we showed in chapter 000, far from learning from these tragedies, the UK boasts of the attractions of its 'deregulated labour market' - a euphemism for a licence to overwork and underpay large sections of the workforce.

Karoshi takes place in Britain as well. In January 1994, junior doctor Alan Massie collapsed and died in Warrington District Hospital at the end of an 86-hour work week (Observer 10 April 1994). He had worked seven of the previous eight days including two unbroken spells of 27 hours and one of 24 hours. His death came at a time when the Government claimed that it had introduced a new deal for junior hospital doctors whose working hours were restricted to a maximum of 83 per week in April 1993. However a survey by the British Medical Association in January 1994 found that 1,200 doctors were still working beyond the limit, though this figure is disputed by the Government.

Chris Johnstone was so alarmed by the extremely long hours, 88 per week, he worked as a junior hospital doctor that he brought an action for personal injury against his employer, Bloomsbury Health Authority, in 1990. He comments, "I felt as though I had a bad case of flu, or jet lag a lot of the time. The exhaustion made me clumsy - I'd often spill my food or drinks. I felt like I was unconnected to my body, empty, like a squeezed out tube of toothpaste. I experienced feelings of unprovoked hostility towards my colleagues, especially if they were making new demands on me. Worst of all, despite having entered medicine out of compassion and a desire to help sick people, I found myself resenting the patients. I began dreading each day. Over the months I got more and more ground down, getting increasingly desperate and wondering at times if it might be better to be dead."

Things came to a head when Chris fell asleep at the wheel of his car and drove into a tree when on holiday following a 110 hour working week. Fortunately, no-one was injured but he decided to resign his job and start an action against his employers. He has still not received a penny in compensation and there is no telling when the case might be settled. But he is fighting on behalf of thousands of others in the health service whose health is being sacrificed to the intransigence of managers obsessed with cost cutting and efficiency. His view on the death of Alan Massie: "I feel very sad that this unnecessary death has happened. The Government and Health Service Management know that these conditions are really dangerous. There's such resistance to change. Even their own (inadequate) recommendations on reducing maximum hours to 72 per week by 1995 are unlikely to be met. I suppose it will only be when human considerations are turned into financial constraints in the form of compensation payouts, that they will actually tackle the problem of excessive hours in the health service. In the meantime, we can only hope that no-one else loses their life."

Disorders of the digestive tract

When individuals are under stress, the stomach increases production of hydrochloric acid, which can cause inflammation and eventually lead to sores, or ulcers on the lining of the digestive tract. It has also been suggested that over a long period of time, intense stress levels can increase the risk of developing conditions such as inflammatory bowel disease. In a detailed study of bus work and health, nearly a third of those required to operate OPO (one person operation) system suffered from some disorder of the digestive system including stomach pain, diarrhoea, constipation, loss of appetite and haemorrhoids (Joffe et al 1986).

Effect on the hormone system

The endocrine system produces chemical messengers or hormones which have an effect on almost every organ in the body. Stress can cause both over production and under production of several major components of the endocrine system, which in turn affects the major organs including the heart, lungs and brain, as well as the immune system, which is responsible for the body's defence against disease (Cox 1993). Hormones can also affect sleep patterns and induce changes in behaviour.

Damaged defences

The immune system provides the body's defence against disease. Studies show that workers under stress suffer more minor illnesses such as colds and coughs, and may also be at greater risk of developing cancer. It appears that stress can alter the effectiveness of the immune system, and in some circumstances reduce its ability to defend against external infective agents (such as cold viruses) and tumour growth (Cox 1993). Stress can also make worse existing conditions such as asthma, dermatitis and rheumatoid arthritis.

Other physiological effects

In 1990, a major study on the effects of office work on the health of more than 2,000 women working for the Inland Revenue was carried out by researchers from the University of Manchester Institute of Science and Technology (Bramwell and Davidson 1990). The researchers found that there was a clear link between stress at work and menstrual disorders. Few previous studies have considered occupational causes of menstrual disorders - and the medical profession tends to treat only the symptoms of menstrual disorders when they are reported. In the London Hazards Centre's previous work with women from a wide range of occupations, menstrual disorders appeared often to be a sensitive indicator of exposure to chemicals, dust, and excessive levels of stress. This anecdotal finding is given more weight by the results of the Inland Revenue study.

In addition to the effects on the menstrual cycle, it has been suggested that stress can affect pregnancy. In particular, work organisation involving shiftwork or night work (which is more stressful than fixed day schedules) increases the risk of miscarriage (Infante-Rivard et al 1993) (see page 00). Stress has been implicated as a factor in some of the clusters of miscarriages reported in groups of VDU workers, and work-related fatigue has been shown to increase the risk of premature birth (Colie 1993). Other studies have shown that women in jobs with high demands and low control were more likely to suffer miscarriages, stillbirths, and have low birth weight babies.

Mental health

Numerous studies of workers in stressful occupations show high levels of mental ill-health. A recent study of stress in UK teachers showed that they are now experiencing stress levels as high as air traffic controllers and GPs (Travers and Cooper 1993). Symptoms of mental ill-health such as anxiety, and depression were common, with poor management structures, constant changes in government policy on schools, and workload being important causes. A similar pattern of stress-related mental ill-health was found by a recent survey of further education lecturers (NATFHE Journal Spring 1994). The problems of overload accounted for many of effects on lecturers' health. The following are a few of the quotes extracted from the survey:

'Stress undermines overall confidence so you feel less confident in class with the students'. 'I have never worked so hard, been so tired, so bad tempered'. 'The health of our staff is appalling. Most suffer from some form of stress-related illness. Many are teaching while taking anti-depressants or sedatives...it is usual for two or three staff to break down a year'.

The mental health of blue collar workers is also at risk from job stress. A three year study of electrical factory workers in Japan showed that job overload and lack of control over the workplace caused high levels of long lasting depressive symptoms in the workforce (Kawakami et al 1992). This finding is typical of such studies.

Stress is certainly the primary cause of the condition which has come to be known as 'burn out'. The three main components of burn out are emotional exhaustion manifesting as tiredness, irritability, accident proneness, depression and excessive alcohol consumption, 'depersonalisation' - treating other people as if they are objects, and reduced productiveness accompanied by feelings of low achievement. Burn out can occur when mechanisms adopted by individuals for coping with unrelenting stress eventually impair that person's normal functioning.

In the most stressful occupations, in particular in health care work, levels of suicide are alarmingly high. UK doctors have a 72 per cent greater risk of suicide than the general population (British Medical Association 1992). Of great concern are the statistics showing that doctors practising in the UK but born overseas are at further increased risk of suicide - suggested that among other factors, discrimination may be adding to already intolerable stress levels.

Post traumatic stress disorder (PTSD)

Emergency service workers such as firefighters and ambulance staff frequently have to deal with grisly, terrifying and sometime violent scenes. Following a major disaster some workers may experience extreme anxiety which is often characterised by repeated re-experiencing of the traumatic event. As many as 15 per cent of all front line London Ambulance staff suffer from PTSD (COHSE 1993). The impact of long-lasting PTSD is considerable and can affect the sufferer's work, family and general quality of life. As more employees such as social workers, bank workers, and housing workers, are exposed to traumatic, violent situations, so more run the risk of developing PTSD.

Several unions whose members are at risk from PTSD have produced guidance and models policies. Details of the policy on responding to incidents of PTSD, negotiated between the train drivers' union ASLEF and British Railways Board are summarised on page 00 in Part 3 of this book.

Psychosocial effects

Some of the ways in which people try to cope with stress can cause ill health. Stress is often expressed by the increased consumption of caffeine, alcohol, cigarettes and other drugs such as tranquillisers. In the 1990 survey of women in the Inland Revenue it was found that the higher stress levels among VDU workers compared to non-VDU workers was resulting in increased consumption of alcohol and cigarettes (Bramwell and Davidson 1990). GPs often respond to complaints of stress by prescribing tranquilisers and sleeping pills. Fortunately, the dangerous effects of long term use of such drugs is now being recognised, as is their inability to tackle the causes of the problem. Smoking causes cancer. Alcohol damages the liver and affects behaviour. Drugs and alcohol can impair the ability to work and disrupt personal relationships which may in turn worsen stress levels.

People under stress can be irritable, withdrawn, appear irrational, aggressive or even violent. This altered behaviour can also impact on relationships inside and outside work. Workers in high-stress occupations are more likely to suffer breakdown of relationships, family break up and divorce.

Workers under stress are far more likely to have accidents than workers in low stress jobs, and are much more likely to have to take time off work for stress-related sickness. In jobs where work overload is the cause of the stress, the workers find that they have to take time off to deal with the stress, only to return to work to find that the already unmanageable workload has substantially increased in their absence, thereby increasing the source of the stress and fuelling a vicious cycle which may ultimately lead to a complete breakdown in health.