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