Global Inequalities at Work:
Work’s Impact on the
Health of Individuals,
Families, and Societies
JODY HEYMANN, M.D., Ph.D.,
Editor
OXFORD UNIVERSITY PRESS
Global Inequalities at Work
This page intentionally left blank
Global
Inequalities
at Work
Work’s Impact on the Health of
Individuals, Families, and Societies
Edited by
JODY HEYMANN, M.D., Ph.D.
1
2003
3
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support. Her able help laid indispensable groundwork.
Soon after I conceived this project, I raised the idea of a book with Jeffrey House at
Oxford University Press. His wisdom and guidance regarding the best way to develop
a meaningful book out of this diverse and rich collaboration has both left an indelible
mark on this book—and taught me a great deal for future ones.
It is true for all authors that their writing is strengthened by others turning a criti-
cal eye on it. In addition to my reviews and editorial comments, every chapter was
carefully reviewed by Alison Earle. Her additional editorial eye was invaluable. Her
critical insights improved countless aspects.
Authors faced the challenge of writing across linguistic and disciplinary bounds.
Sharon Sharp helped edit the language so that the volume could speak with the more
than a dozen different voices and perspectives it has but be accessible to readers. I am
deeply grateful for her gifted work on this project.
The making of a book has craft to it as well as ideas, understanding, and writing.
And part of the process of that craft is attending to the details from formatting manu-
scripts to checking references. I am particularly indebted to Stephanie Simmons, who
patiently took on this task as her first job as a member of my team. The book you read
reflects the care and quality of her work.
While they are thanked in the introduction to the text, particular thanks are due
here to all the contributors to the volume. To the extent to which the book succeeds
in being more than the sum of its parts, it owes a great debt to the individual authors
who were willing to think beyond the boundaries of their own endeavors.
Neither last nor least, this initiative would not have been possible without the sup-
port of the Center for Society and Health at Harvard University, where I have served
as Director of Policy. The support of the small faculty group that formed the Center
with me at its start—Lisa Berkman, Ichiro Kawachi, and Nancy Krieger—as well as
Acknowledgments
those who joined before the authors’ conference—Norman Anderson and Laura
Kubzansky—truly made the initiative both possible and far richer than it would have
been without them.

Part II The Broader Impact of Global Working Conditions:
The Effect on Families
4. Labor Conditions and the Health of Children, Elderly and Disabled
Family Members, 75
Jody Heymann, Aron Fischer, and Michal Engelman
5. Maternal Labor, Breast-Feeding, and Infant Health, 105
Susanha Yimyam and Martha Morrow
6. Parental Labor and Child Nutrition Beyond Infancy, 136
Peter Glick
Part III The Relationship between Work and Population Health
7. Wage Poverty, Earned Income Inequality, and Health, 165
S. V. Subramanian and Ichiro Kawachi
8. Gender Inequality in Work, Health, and Income, 188
Mayra Buvinic, Antonio Giuffrida, and Amanda Glassman
9. Women, Labor, and Social Transitions, 222
Parvin Ghorayshi
Part IV Globalization of the Economy:
The Risks and Opportunities It Creates for Health
10. Work and Health in Export Industries at National Borders, 247
Catalina A. Denman, Leonor Cedillo, and Siobán D. Harlow
11. Opportunities for Improving Working Conditions through
International Agreements, 278
Stephen Pursey, Pavan Baichoo, and Jukka Takala
12. The Role Global Labor Standards Could Play in Addressing Basic Needs, 299
Kimberly Ann Elliott and Richard B. Freeman
Index, 329
xii Contents
About the Editor
Jody Heymann is Founder and Director of the Project on Global Working Families at
Harvard University. This research program involves studies on the working condi-

chemical safety liaison with United Nations
Environment Programme and as the officer
concerned with issues surrounding the Interna-
tional Organization for Standardization (ISO).
Mayra Buvinic is Chief of the Social Devel-
opment Division, Sustainable Development
Department at the Inter-American Develop-
ment Bank. Before joining the Bank in 1996,
Ms. Buvinic was founding member and Presi-
dent of the International Center for Research
on Women. Ms. Buvinic has published in the
areas of poverty and gender, employment
promotion, small enterprise development,
reproductive health and, more recently, vio-
lence reduction.
Leonor Cedillo is currently leading the
Risk Analysis program at the General Direc-
torate of Environmental Health at the Federal
Commission for the Protection of Sanitary
Hazards of the Mexican Ministry of Health.
She was founder of one of the first nongov-
ernmental organizations in Mexico set up to
collaborate with workers’ organizations in
evaluating and developing proposals for im-
proving their occupational health conditions.
David C. Christiani is Professor and Di-
rector of the Occupational Health Program in
the Department of Environmental Health at
the Harvard School of Public Health. His re-
search interests are occupational, environ-

Kimberly Ann Elliott is currently a Re-
search Fellow at the Institute for International
Economics and an adjunct professor at the
Johns Hopkins School of Advanced Interna-
tional Studies. She has contributed to numer-
ous books and articles on trade policy issues
xvi Contributors
including international labor standards, the
uses of economic leverage in international ne-
gotiations, and the causes and consequences
of transnational corruption.
Michal Engelman is a member of the
Project on Global Working Families, led by
Jody Heymann at the Harvard School of Pub-
lic Health. She has analyzed data gathered by
the Project from Mexico and Botswana, and
launched the Project’s most recent study in
Russia. She has researched international com-
parative social policies and work and family
issues including aging and eldercare, early
childhood development in developing coun-
tries, and gender inequalities in education.
Luiz A. Facchini is the Secretary of Health
for the Municipality of Pelotas, State of Rio
Grande do Sul, Brazil. Previously, he served
as the Director of the Department of Social
Medicine, Federal University of Pelotas. He
has served as a consultant to the Pan Ameri-
can Health Organization (PAHO) and the
Brazilian Council of Research among numer-

nomic Performance at the London School of
Economics. He has published extensively in
labor economics and policy including the
effects of immigration and trade on inequal-
ity, restructuring European states, and Chinese
labor markets, among other areas.
Adepeju Gbadebo worked with the Project
on Global Working Families to conduct in-
terviews on the interactions between human
immunodeficiency virus/acquired immuno-
deficiency syndrome and employment in
Botswana. She has also researched health eco-
nomics in the United States and co-authored
“Economists on Academic Medicine” in the
journal Health Affairs.
Parvin Ghorayshi is a Professor in the
Department of Sociology at the University of
Winnipeg, Canada. Her research interests
include feminist theories and gender relations
in developing countries, with a focus on the
Middle East. She is the author of Women and
Work in Developing Countries (1994) and co-
editor of Women, Work, and Gender Relations
in Developing Countries: A Global Perspective
(1996). Her most recent publications appear
in the Canadian Journal of Development Stud-
ies, Women and Politics, Anthropologie et So-
ciétés, and Gender, Race and Nation: A Global
Perspective.
Antonio Giuffrida is an Economist work-

Siobán D. Harlow serves as Associate
Director of the International Institute and
Associate Professor of Epidemiology at the
University of Michigan. In collaboration with
her Mexican colleagues, she has conducted
research on the health status of female work-
ers including projects focused on domestic
workers, street vendors, and maquiladora
workers. Her research focuses on under-
standing how life circumstances and biologi-
cal processes unique to or more common
among women influence their health status
across the lifecourse.
Ichiro Kawachi is Professor of Health and
Social Behavior and the Director of the Harvard
Center for Society and Health at the Harvard
School of Public Health. His research concerns
the social and economic determinants of popu-
lation health. He is the coeditor with Lisa
Berkman of the first textbook on social epide-
miology, published by Oxford University Press
in 2000, as well as a forthcoming volume, Neigh-
borhoods and Health. He is the Senior Editor of
the journal Social Science & Medicine.
Maria de Fátima Maia is Associate Re-
searcher in the Department of Social Medi-
cine at the Federal University of Pelotas,
Brazil. Her research in the area of occupa-
tional epidemiology focuses on child labor
and health.

analyzed data from the Project’s Botswana
site. Previously, she wrote and edited pieces
on a range of social and economic issues in
both domestic and international contexts,
including work and family policy, child and
maternal health, reproductive rights, and the
acquired immunodeficiency virus. She was
formerly a Writing Fellow at The American
Prospect magazine and a teacher at the Ameri-
can International School in Israel.
xviii Contributors
S. V. Subramanian
is Assistant Professor
of Health and Social Behavior at the Harvard
School of Public Health. His research includes
refining the practical applications of multi-
level methodologies to understand the macro-
determinants of health and social inequalities
and developing comparative international per-
spectives in health and social behavior. He has
published in international social science and
health journals on the influence of income in-
equality, social capital, and, more broadly, geo-
graphic contexts on population health.
Jukka Takala is the Director of the Inter-
national Labor Organization’s program on
Safety and Health at Work and the Environ-
ment. Before holding this position, he served
at the ILO as Chief Technical Advisor and Ex-
pert in Occupational Safety and Health in

1
Introduction: The Global Spread of Risk
JODY HEYMANN
Leti, Humberto, and Laura each lived with their families in different corners of the
hillside slums surrounding Tegulcigalpa. When the expression “pale as a ghost” is
used, it is often employed in hyperbole. But the phrase hit the mark in describing
Leti’s infant daughter, Valentina. She was so malnourished that her skin was nearly
translucent because there was none of the normal baby fat below the skin. Leti had
had to return to work 42 days after giving birth or lose her job. She had no choice
but to stop breast-feeding at that time—in spite of the fact that it was clear that she
could not afford enough infant formula on her low wages to nourish Valentina ad-
equately. Like the majority of children who are not breast-fed long enough in poor
parts of the world where safe drinking water is unavailable, Valentina rapidly grew
sick, first with intestinal and then with respiratory infections. When we met her,
she was barely moving.
Humberto and his wife, Geralda, both worked in factories to make ends meet. If
Geralda wanted to keep her job, she too had no choice but to return to work soon
after giving birth and cease breast-feeding. Yet, not breast-feeding placed her son, like
Valentina, at heightened risk of infections. Within a few months, Humbertocito was
hospitalized with pneumonia. Like many overburdened hospitals in developing coun-
tries, the hospital relied on family members to provide essential care. Humberto asked
for permission to take time off from work to care for his son. On the first day, permis-
sion was granted; on the second day, he received a warning. On the third day, he was
fired and blacklisted from other factory jobs.
Laura was raising her 18-month-old daughter alone since the death of her husband.
She worked in a foreign-owned factory 7 days a week. The shifts were inhumanely
long—ranging from 15 to 22 hours a day. But it had been the only job she could find.
It was summertime, and Laura’s niece temporarily provided care for her daughter,
but she was due to return to school in a month. Earning only $26 every 2 weeks and
having to pay $14 to the factory for the one meal a day she received, Laura earned too

for protection.
During the Renaissance, concern about the impact of dangerous jobs and trades on
those who performed them reemerged. In 1473, Ulrich Ellenbog wrote On the Poison-
ous Evil Vapours and Fumes, a manuscript about the hazards to which those working
with metals were exposed (Barnard, 1932). Georgius Agricola (1494–1555) underscored
the effects on individual workers’ health of mining and smelting gold and silver in De
Re Metallica. Paracelsus (1493–1541), a physician who traveled throughout Europe,
treated and wrote about those who fell ill while working at these occupations.
Perhaps not surprisingly it was the Enlightenment, with its many humanitarian
reforms, that sparked the first detailed examination of how individual health was af-
fected by a wide range of occupations. In 1713, the Italian physician and professor of
medicine Bernardo Ramazzini wrote De Morbis Artificum Diatriba, an account of
workers’ diseases in approximately 100 professions. Ramazzini wrote about occupa-
tions that ranged from metalworking to sewer cleaning, from making glass to deliver-
ing infants as a midwife, from being an intellectual to being a potter.
Thus, a long and important history of both research and medicine has focused on
the impact of working conditions on health. Originally dating back to ancient Greece,
Introduction 3
investigations into the risks of working in different occupations were first seriously
revisited during the Renaissance. However, while both the breadth and the depth of
our understanding of individual risks have expanded in important ways since the En-
lightenment, the focus has remained largely on the individual.
Providing Individual Workers with Protection from
and Compensation for Physical and Chemical Exposures
The focus on individual health effects has led to important policy developments as
well as treatises. Beginning in the 1800s, a series of laws were passed to provide pro-
tection for individual workers. The British Factory Act of 1855 provided for the in-
vestigation of industrial accidents. In 1897, the Workmen’s Compensation Act ensured
that those injured on the job in Britain would receive remuneration from their em-
ployers. In 1906, compensation was expanded to include those who developed seri-

scribe only some of the policies passed and programs initiated to reduce the risks as-
sociated with work.
The efforts made by industrialized nations both independently and collectively,
while not removing all hazardous exposures, have dramatically improved the safety
of workplaces in these countries.
The Gaps Left by a Focus on Individuals
While the importance of the progress made in decreasing the risks faced by individual
workers cannot be overstated, these advances have had two major limitations. First, while
North American and European countries were addressing hazardous exposures, com-
panies were moving factories to countries where regulations were less rigorously enforced
or were nonexistent. Unskilled workers in poor countries were facing increasing haz-
ards from both imported and home-grown industries as the speed of industrialization
in their countries far outstripped the pace of new protections. Second, the protections,
by and large, addressed only the health of individual workers. Working conditions were
simultaneously having a dramatic effect on the health of families around the world, as
they did for Leti, Humberto, and Laura. Yet, the broader effects of working conditions
on the health and well-being of families and societies were not being addressed.
In effect, the field of occupational health has mapped one continent—that of indi-
viduals in industrialized countries—extremely well, but much territory has been left
uncharted. A map of the relationship between work and health that is truly global—
both geographically and in its coverage of the impact of work on the health of indi-
viduals, families, and societies—has not been drawn.
The relative paucity of attention paid to the impact of working conditions on the
health of families, societies, and the global community is evident from an examina-
tion of published research on occupational health and a review of what is being taught.
In a review of 30 occupational and environmental health programs from the United
States, Canada, Australia, the United Kingdom, South Africa, Finland, Sweden, Thai-
land, Singapore, and Hong Kong, only two listed courses that examined the impact
of working conditions on levels beyond the individual.
1