Occupational Medicine: Why is everyone lying down?

Introduction

Source

Understanding that occupational health is probably one of the most sub-par aspects of Cambodia’s medical system, I have decided to address the recent factory fainting epidemic. In 2011, mostly since April, there has been a wave of mass fainting in Cambodian garment factories. While there have probably been such occurrences before 2011, I cannot find clear reports. Even those incidents that have been reported recently often have unclear reporting of the number of workers, the date and multiple spellings of factory names. From news reports this is the most accurate timeline that I could gather but it could certainly be wrong.

• Apr. 9-10: 100 to 200 workers at the Huey Chuen Factory (Phnom Penh), supplies Puma
• Jun. 15: 200 workers at the King Fashion Garment Factory (Phnom Penh)
• Jun. 16: 100 workers at the King Fashion Garment Factory (Phnom Penh)
• Jul. 25: 49 workers at the Huey Chuen Factory (Phnom Penh), supplies Puma
• Aug. 23: 86 workers at the Hung Wah Factory (Kampong Chhnang), supplies H & M
• Aug. 25: 198 workers at the Hung Wah Factory (Kampong Chhnang), supplies H & M
• Aug. 26-30: 40-100 workers at the Chime ly Garment Factory (Phnom Penh), possible Walmart Canada Supplier
• Sept 2: 20 workers at the Shingly Garment Factory (Phnom Penh)

This accounts on a high estimate for about 953 fainting incidents. The Ministry of Labor recently announced that 1,578 individuals so far this year have been reported fainting in factories. The discrepancy could be accounted for by missing fainting accounts I have not been able to find or by a large number of individual fainting incidents (Source). Pok Vanthat of the Ministry of Labor’s Medical Unit explained that the main causes are insecticides, smoke, high temperatures, stress and manual labor (Source).

Each of these incidents have been investigated to varying degrees, mostly based upon the publicity and companies involved (the Puma and H&M factories have led to a considerable amount of bad press and therefore more active involvement from international agencies).

Some interesting descriptions of the events:

“Some women got weak in the knees and fell, some started choking, and for others their hands and legs began trembling and shaking before they fell,” Un Dara, president of the Independent Union Federation, said (Source). 

Nhoem Srey Touch, 22, who was treated at Bek Chan Health Centre, said she began choking and her limbs went numb. She said she also panicked when women around her began collapsing. “I was so terrified I lost consciousness,” she said (Source). 

One employee at the Chime Ly factory, who asked to remain anonymous, said the fainting occurred just as the workers were returning from lunch. “The building is too hot and lacks fans. It is too crowded. The smell from the chemical substance the clothes are treated with caused us to faint,” she said. “Not only the workers inside the building fainted—the guards outside also collapsed” (Source).

Multiple investigations have yielded many answers with a varying degree of confidence and practically no concrete explanation.

Poor Ventilation:

Poor ventilation is one of the most common reasons listed by investigators and factory workers. This explanation is one that factory owners and executives are not completely satisfied with as it lays blame on building construction, utilization and maintenance. Poor ventilation is explained as a result of cramming too many workers into buildings, poor building construction and blocking vents with clothing piles (Source). In my opinion the actual flow of air is probably not as important in fainting incidents as the heat caused by the same conditions.

Chemicals:

This explanation is even more unpopular with factory owners and executives than poor ventilation for obvious reasons. A report by the Fair Labor Association after the first Puma factory fainting incident found many "hazardous chemicals," including toluene that violated Puma's own factory health standards. The study also added that chemicals were probable a 'strong possibility' (Source). Greenpeace has also noted traces of 14 toxic chemicals in top clothing brands (Source).

“Psychological Phenomenon”/Hysteria/Spirit Possession:

In one of the articles I read an executive associated with one of the factories which is run by a Macau company was quoted as saying that the reason for the mass fainting was a "strange psychological phenomenon" (Source). He continued by saying that

“In China, this kind of thing is unthinkable. We can’t understand how this happens so often in Cambodia,” said the executive who asked to remain anonymous. 

“The workers don’t pass out at once, they pass out in succession. One worker passes out, and when another sees this and she passes out, then another and another and another. It’s beyond my comprehension.”

Obviously they should trade out the Cambodian models for the more durable Chinese worker. This idea, that the fainting incidents are a result of some hysteria or psychological issue is attractive to executives because it removes blame almost completely from the factories. Nevertheless, hysteria is an important part of the puzzle. If we were trying to explain consistent individual fainting episodes, explanations like ventilation or malnutrition may be adequate. These, however, are mass faintings. There needs to be an explanation why everyone goes at once and in my opinion it is most likely linked to panic of seeing other people begin to pass out, almost like how one person vomiting inspires others. There needs to be a social aspect to the phenomena. Most of the first-hand accounts describe the incidents in this way, like a wave flowing through the factory. This does not discount the other factors, as they create the adequate environment for passing out.

Chuop Sam Ol, from the MV factory, traces this factory's fainting to a a single worker (Source).

“It’s not a big problem. It was because the worker was weak. She did not sleep enough the night before. Her relatives were sick. She tended to them and had to stay awake. Therefore when she came to work in the morning she did not feel well,” she said. “She works in Building L. Later, she collapsed. When the others saw this, they became panicked and started fainting one by one.”

Before proper inspection, one factory manager blamed the mass fainting on spirit possession (Source). One factory, after correcting flaws identified by the ministry of labor, called monks to bless the building at the bequest of the workers. Also fitting into this section, Yi Kithana who is the deputy directoy of the Labour Ministry's occupation health department said that many of the people who fainted suffered from mental illness (Source).

Malnutrition/Hypoglycemia:

There are many references to doctors claiming that the workers who have been seen at the hospital have very low blood sugar (Source). Ken Loo, from the Garment Manufacturers Association in Cambodia seems to like this explanation (Source).

“The main observation of medical professionals who examine these workers that have fainted is that they all have low blood sugar,” Ken Loo added. 

“I would assume that’s because they either skip breakfast or [eat] something which is extremely light.”

This could certainly be a contributing factor and it once again lays blame on the workers for 'skipping' meals. Workers turn this around a label it as a wage and time issue.

Working Overtime

I was surprised by how many articles that listed explanations of the fainting epidemic also referenced important elements of labor disputes, such as working overtime and not getting paid vacation/sick days. Overwork/exhaustion could be an issue as production demands increase, though most factories deny these claims. I find these explanations interesting not because of their possible causal relationship but because of how these fainting episodes are going to shape the labor dispute. Were I a genius union organizer who realized that dozens of strikes a year were not improving the labor situation I may decide to orchestrate mass fainting incidents. This is not what happened. I just want to point out how much these incidents and reports are going to do for working conditions. They are putting more pressure on the government and companies than a strike ever could. This pressure and influence is not just covering traditional occupational health but is pouring over into wage discussions and benefits.

Surgical Masks

Source

This was not mentioned in any article but as I leisurely viewed this nice picture of a Cambodian garment factory one thing overwhelmingly captured my interest. I’ve mentioned complaints about toxic chemicals, bad smells, poor ventilation and heat. I was stunned that all of these girls are wearing surgical masks. Please note the presence of the mask in the picture of the girl who fainted above. It’s Asia. Everyone wears masks. Not a big deal, right? These masks can only help...right? No.

I remember about 9 years ago as I was working laying down flooring. I was mixing some nasty chemical glue while wearing a cheaper respirator mask. My benevolent co-worker explained to me that if I wore that mask I would die, because it was not rated to keep out the strong chemical I was mixing, would actually trap the chemical in front of my face and would restrict my airway. I got to put on a heavy duty mask. Not all masks are created equal.

These girls are wearing surgical masks. These masks are meant for one thing, to restrict the transfer of bodily fluids (saliva, blood, etc.). Generally it is far more useful to protect the surrounding population than the person wearing it, which is why sick people are counselled to wear them. Doctors wear them so they don’t sneeze and spit on patients with compromised immune systems (as well as the splash protection afforded). They don’t keep out dust and particulates very well. They also don’t filter out noxious fumes or any other gases for that matter. They do serve to trap many of these things and hamper ventilation.

I have recently read quite a few anecdotes about medical students passing out. Pshaw. Medical students see blood and gore that they are not used to and it makes them light headed - bam. While this is certainly the case in some instances, it seems that it is not the only cause of syncope. Many students reported wearing masks improperly, wearing them too tight, or just not being used to wearing them as the primary reason for syncope. Panic (caused by decreased airflow) causes people to breath in deeper, there is further restricted airflow, increase in heat and even greater panic. A 2009 study listed the major causes of syncope in medical students as heat (79%), prolonged standing (73%), surgical masks (47%) and the smell of diathermy (18%) (Source).

In summary these masks can only serve to amplify the problem. They increase the dangers of chemical fumes, hysteria and malnutrition that have been mentioned earlier. Furthermore they could be a primary cause of fainting in their own right.

Here is a wonderful instructional video about surgical masks and respirators.

 

Here is some additional information on masks from the CDC and the International Safety Equipment Association.

Going Forward:

It is extremely important that this issue is resolved and that advances in the country's occupational health infrastructure and policies are made. The garment sector is a vital part of Cambodia's economy, employing more than 300,000 workers. It has also been plagued with riots, protests and multiple accounts of sexual harassment and employee abuse.

Multiple investigations have been and continue to be conducted. Including this one by the International Labor Organization. These investigations following these incidents have led to the ministry making recommendations about work spaces, hygiene and food (Source). It is yet to be seen however, if these recommendations will be implemented and if there will be repercussions if they are not. The occupational health department of the government seems to be one that is particularly vulnerable to corruption as it is probably a target for any large business that wants to cut costs. Both integrity and efficacy need to improve greatly before workers can be guaranteed health in the workplace. This is much larger than the garment and textile industry.

Further Information:

If you want to learn a little more about Cambodian factory workers I found the following videos very interesting.

Factory Shorts: Looking at Cambodia's Garment Sector

Better Factories Cambodia - At the Factory Gates Episode 1 and 2 Trailer

Better Factories Cambodia - At the Factory Gates Episode 3 Trailer

Coin Rubbing Part 2 (Addition)

The first post addressing studies showing possible physiological benefits/pathways of coin rubbing was getting too long so I did not include the following. Nevertheless, the content is important enough that I felt I needed to create an addendum.

A website associated with Vanderbilt University, written by a student in 2006, gives a brief overview of Cao Gio  (coin rubbing). At that time the student mentioned that no papers were written on the efficacy of the practice but that there were a variety of sources addressing the balms and oils that are used. It is entirely possible that any perceived benefits of the practice do not come from the rubbing at all but rather the tiger balm or menthol used. It is also possible that the oil and the rubbing activate different pathways. I am not going to summarize these articles like I did the others because it has already been done, but if you are interested here is the link. Scroll down to Other Perspectives. 


Among possible benefits perceived are reducing circulatory disorders and relieving tension headaches. The website mentions my favorite blanket explanation, the placebo effect and also points out that efficacy is hard to evaluate because coin rubbing is often used in tandem with bio-medical remedies.  

Coin Rubbing Part 3: Adverse Complications

My wife lives by the idea that medicine is a double sided sword and I have generally found that to be true more often than not. It was a shock to me when I learned that medicines I had considered benign as a child could actually have some pretty nasty side effects (ibuprofen, aspirin, etc...). Additionally, I am aware that traditional or alternative therapies that claim to have few side effects can often have disastrous ramifications. While I was volunteering with Operation Smile Cambodia I saw a horde of Cambodians that came through screening with extensive scars resulting from serious burns associated with "cupping".

Coming from this experience and perspective I expected to find at least some adverse side effects of coin rubbing. Surely there should be some physiological ramifications. Long term dermatological issues? Problems in pregnant women? Permanent damage to infants? Blood poisoning? I have not been able to find reports of any of these problems. Indeed it seems that the psychological ramifications of the "child abuse" label in the U.S. may be the most serious side effect (Besides, of course, the pain, discomfort and bleeding that accompanies the process). To some extent I am disappointed. While it would be wonderful to have a healing method that treats a variety of symptoms with absolutely no long term drawbacks, the absence of any complications tempts me to doubt its authenticity. If a procedure does something physiologically significant, the pathways should be able to cause harm as well as heal. I understand that many alternative healing methods follow the mantra that we need to open pathways to "allow the body to heal itself". Even the body's healing mechanisms have the potential to cause serious harm however (autoimmune disease, prolonged fever, clotting or lack thereof). On the other hand maybe the visible temporary side effects, which could cause nerve desensitization and increased circulation, are more than adequate and I am making something out of nothing.  

The only reports that I was able to find that relate at all to dangerous coin rubbing side effects addressed camphor intoxication and burns (associated with some practitioners who heat the oil they use).

Camphor Intoxication After Cao Gio (Coin Rubbing)

Cutaneous Side Effects of Alternative Therapy


 

Coin Rubbing Part 2: Studies on Physiological Benefits

To preface, I was very disappointed with the available literature on coin rubbing, and traditional medicine in general. This is both because of the dearth of scientific studies and the general quality of those that have been conducted. Traditional medicine is traditionally avoided by the western scientific community because it is not based on current world view/understanding of physiology and biology. There has been an increase in recent years of studies that have sought to identify a scientific basis behind traditional medicine but they are still few and far between. The studies that have been done are primarily relegated to journals with questionable underpinnings (journals dedicated to Chinese integrative medicine that are attached to schools of integrative medicine, for instance). Traditional/holistic/integrative/experimental medical techniques, perhaps because of the common ground of bio-medical rejection, are generally grouped together. As a result it is often difficult to pick and choose which healing techniques may have seeds of legitimacy and which ones have little benefit at all. In bio-medical journals the peer review process is cannibalistic. Scientists and physicians work hard to disprove, replicate and authenticate studies before they are published. I realize that this is not always the case but relative to alternative healing journals biomedical science is exclusive. I get the feeling that alternative healers are often willing to include any validation for any alternative healing theory because they are on the same side of the battle. Obviously this is not the case across the board but I do think that there is a significant difference in atmosphere. Regardless, some progress, however little, has been made.

Here are some of the studies that I have been able to find on the physiological benefits of coin rubbing. I think it is important to group them into two separate categories, studies which attempt to aid understanding of a biological mechanism and studies which try to show if coin rubbing actually does anything at all.

Randomized controlled pilot study: Quantitative sensory testing in patients with back pain before and after Gua Sha massage (Source)
Published in European Journal of Integrative Medicine, 2009

Experiment Design: 30 patients with back pain were put into a treatment group (TG) or waiting list control group (WLC). Patients were asked to rate their pain and then coin rubbing was started in the TG group after getting a baseline sensory data. After 7 days more sensory data was taken and the WLC received the treatment. Sensory data included mechanical detection threshold (MDT), pressure pain threshold (PPD) and vibration detection threshold (VDT). It was take at the site of pain, 10 cm next to the pain and two control areas.
Results: Decrease in pain ratings when comparing TG vs. WLC. There was no difference in VDT anywhere. While there were also no differences at site of maximum pain, the 10 cm mark showed increased MDT and PPD.
Conclusions: TG received a 35% decrease in self reported pain intensity, the control did not. It appears through the changes in thresholds that there were functional changes in the sensitized areas.
Analysis: This study sets out to show both that there is significant pain reduction and tries to probe where this might be taking place. I really wish that the control group was handled differently. Having the control group wait to receive the treatment does not counteract any psychological factors. Would having someone lightly massage your back, or talk to you about your problems or use a heat pack have given the same decrease in pain intensity? This is something that I feel that many of the people studying these traditional treatments are afraid to explore. Understandable it is difficult to find a good experimental procedure that finds its way around some of these problems but to be convinced I really need something more elegant. The only reason I like this study is because I think that if coin rubbing is doing anything physiologically, the most likely mechanism is through a change in the nervous system. The threshold information is interesting but we ultimately need experiments that can both confirm and explain this finding.    

Changes of bilirubin,SOD,IL-1,IL-6 and WBC count before and after Guasha treatment in rats (Source)

Published in Journal of Beijing University of Traditional Chinese Medicine, 2009

Experiment Design: Blood was taken from individuals with no coin rubbing, after a half hour of coin rubbing, after 6 hours of coin rubbing and after twelve hours of coin rubbing. They were then tested for the following compounds: bilirubin, superoxide dismutase (SOD), interlukin-1 (IL-1) and IL-6.
Results: Compared to the normal group, the 6 hour group had a lower white blood cell (WBC) count and a high level of bilirubin and the 12 hour group had very low levels of SOD.
Conclusion: From the data they concluded that the inflammatory reaction of WBC was inhibited and bilirubin was increased. They suggested this may be how fever is decreased and diseases cured. 

Analysis: This study fits into the category trying to find a mechanism. They do not specify which SOD enzyme but from what little I have been able to learn you don’t really want low levels. It is an important antioxidant and its mutation or absence is linked to a wide variety of diseases. Bilirubin is also an antioxidant but with different functions as well. It is a breakdown product in the catabolism of heme (the yellow color on your bruise). I do not have the necessary background to really make a valid argument or assessment but it seems to me that the differing blood levels of these compounds would be the natural product of widespread scraping and bruising. There is no explanation or hypothesis as to the mechanism by which fever would be abated or other healing would be initiated. While this study may or may not be perfectly legitimate as a building block (I really don’t know) there is not enough data to claim any conclusion as to the usefulness of coin rubbing and the publication source may present enough bias as to make it unacceptable.

Effects of Gua-Sha Therapy on Breast Engorgement: A Randomized  Controlled Trial (Source)

Journal of Nursing Research, 2010

Experimental Design: Randomized trial on 54 postpartum women in a teaching hospital. These women had both uncomplicated delivery and breast engorgement problems. Positions were identified and scraped consistently. A control group received hot packs and massage 20 minutes which was an instruction in a obstetrics textbook. 

Results: While there was no statistical difference between the groups at baseline, the coin rubbing group had "significant" (p < .0001) differences in body temperature, pain levels and discomfort levels after intervention.

Conclusions: Coin rubbing is an effective procedure that should be used by nurses to help alleviate breast engorgement.

Analysis: This study does not address mechanism at all but overall results on patients’ health. As far as I can tell the study proves that coin rubbing is an effective treatment for this particular ailment. I would like to see the study repeated. I would also like to see a study that addresses exactly why coin rubbing is producing these results but I guess that I am going to have to wait patiently. I really like that the control not only used heat pads but also massage. It is very possible that the personal attention and touch is part of the healing process and using heat pads exclusively would serve to diminish the power of the control.

The Effect of Gua Sha Treatment on the Microcirculation of Surface Tissue: A Pilot Study in Healthy Subjects (Source)

The Journal of Science and Healing, 2007

Experimental Design: Used Laser Doppler imaging to measure micro-circulation of surface tissue. Pictures were taken before and after for 11 patients. There was no control but rather a comparison to the baseline.

Results: Fourfold increase in circulation for the first 7.5 minutes, and significant increase throughout the entire 25 minutes following treatment (p < .001). Pain relief was also noted, and some even during follow up visits. 

Conclusions: Coin rubbing increases microcirculation in a localized area and may be the pathway by which pain is reduced. There is reduced pain in distal areas as well that do not experience microcirculation so there must be an "unidentified pain-relieving biomechanism".

Analysis: Another mechanism study. My favorite part of the article is when they describe coin rubbing as "therapeutic frictioning that intentionally raises transitory petechiae and ecchymosis". Petechiae and ecchymosis is an awesome way to say scraping and bruising. I doubt any traditional practice will be accepted into biomedical practice unless it is described in terms equally impressive. This study shows quite well that local areas increase microcirculation but falls short of identifying any kind of beneficial mechanism that leads toward healing. Regardless, the observations here are an important step in creating a more complete understanding of the process.

Effectiveness of Traditional Chinese "Gua Sha" Therapy in Patients with Chronic Neck Pain: A Randomized Controlled Trial (Source)

Pain Medicine, 2011

Experimental Design: 48 outpatients with chronic neck pain were randomly selected. 24 received coin rubbing, 24 (control) were treated with heat pads. Pain severity was assessed 1 week later. Pain at motion, neck disability index and quality-of-life were also assessed.

Results: Significantly better improvement among coin rubbing patients after 1 week (95% confidence interval). Pain at motion, neck disability index and quality-of-life also showed significant changes.

Conclusions: Coin rubbing has beneficial short-term effects on pain. Long-term management is undetermined.

Analysis: Like the breast engorgement study, this paper addresses whether or not coin rubbing has overall health benefits as opposed to understanding how it works. The lack of a hands-on interactive control, like massage, makes it difficult to isolate whether or not the coin rubbing is important or the attention of the provider is sufficient. This is a pretty straightforward and simple study. We are going to need a slew of these, conducted under different conditions, to really convince the bio-medical community that the procedure is beneficial.

There are a few studies which I have not been able to find in any language but Chinese or German:

Gua Sha Treatment used in the headache after the operations with spinal anaesthesia (Source)

Published in Journal of Clinical Medicine in Practice, 2011

Claims: Coin rubbing significantly decreases headaches in these conditions.

Gua Sha for migraine in inpatient withdrawal therapy of headache due to medication overuse (Source)

Forsch Komplementmed, 2007

Claims: Case study of a single patient shows that coin rubbing may be beneficial in treating headaches.

Perhaps my skepticism is unfounded, but I have a tendency to be suspicious of journals' motivation and incentives. My hope is that there will be an increasing interest in holistic and traditional medical traditions that will lead to more rigorous and thorough studies of these practices. While I have great respect for bio-medicine, I do not believe it to be unassailable and I feel/hope/think that the study of cultural and holistic medicine can compliment what we have learned of healing.