Nearly half a million people live in the few square miles of the Kamrangirchar and Hazaribagh areas of Dhaka, Bangladesh, itself a city of over fifteen million people. These districts are low-income or “slum” areas in the tidal lands and dumps along the Buriganga River. While all of Dhaka suffers from significant air pollution, overcrowding, traffic gridlock, and inadequate infrastructure, the conditions in the slums are much worse—especially for factory workers. The small-scale factory work force includes teenagers “officially” as young as 14, and younger children who assist in the smaller businesses by carrying, sorting, and assembling items, and sometimes operating machinery.  Factory owners’ interests are in producing a product and turning a profit. In Bangladesh, labor costs are low and workers are plentiful, so turnover is often high. In some of the factories, workers’ tenure can be measured in months. Newly arrived workers quickly seek better paying, safer employment outside the area. Some workers who come from remote villages often return to their home village and families. This transient nature of the work force is one of many challenges associated with improving health and safety in a developing economy.  Médecins Sans Frontières (MSF), also known as Doctors Without Borders, has operated occupational health (OH) clinics in the urban slums of Dhaka since 2013. In 2014, MSF conducted more than 4,000 consultations with individual workers as part of an agreement with 233 garment, leather, metal, and plastic factories to offer free care to workers. During these visits, clinical staff noted significant occupational illnesses and injuries among workers, including gastritis, musculoskeletal complaints, respiratory distress, and skin infections. More than 50 percent of the patients had been exposed to high levels of chemicals, noise, or heat, and over 60 percent had not been immunized against tetanus. Workers were generally unaware of personal protective equipment and reported frequent accidents. These observations prompted MSF to increase efforts in the region.
Photos above (clockwise):
Workers operate machinery to make stuffing. Worker tack welding screens without eye protection. Man at work at a tannery in Bangladesh. Photos by Gary Bangs
FACTORY WALK-THROUGHS During December 2016 and January 2017, industrial hygienist and consultant Gary Bangs provided technical support for MSF to conduct assessments in factories in Kamrangirchar to assess worker hazards and identify potential interventions to improve safety in factories. Prior to conducting these assessments, the MSF outreach team contacted the factory owners or managers to establish relationships so that the employees could have access to MSF’s OH clinics. Over the course of two months, assessors observed the working conditions and practices in a number of tanneries, small factories, and workshops, including a range of metal rack, steel frame, aluminum pot, rubber shoe, plastic toy, leather, glue-making, and fabric-shredding and dyeing shops. Most of the factories were small to medium in size and employed from one to 30 workers. The purpose of these field visits was to determine general types of hazards, typical working conditions, factory dynamics or workflow, and the types of exposure controls in place—if any.  Most factories lacked the most basic hygienic measures (for example, potable water) or hazard controls, and these observations were used to design a hazard assessment checklist.  DESIGNING A HAZARD ASSESSMENT To address the types of hazards and general lack of controls in the small-scale factories, Bangs helped MSF design a simple 25-item checklist. The checklist’s yes-or-no questions focused on areas such as fire and life safety; hygienic measures; engineering controls, including lighting and ventilation; PPE; hazard communication; and ergonomics. The back of the form featured explanations for each item. The hazard assessment checklist included only observable conditions and hazards so that subsequent changes or improvements could be easily documented by future assessors.   Together with the MSF environmental health officer, or EHO, Bangs conducted a day-and-a-half training for assessors to discuss occupational hazards, the hierarchy of controls, and how to use the checklist to assess each hazard. Hazard assessments were conducted by MSF outreach teams under the direction and guidance of the EHO. With a translator’s assistance, the EHO and outreach supervisor developed a standardized message for factory managers.
Workers in a barrel-making factory wearing hearing protection. Photo credit: William S. Carter
ASSESSMENT FINDINGS MSF outreach teams performed hazard assessments in 150 factories in 2017. Most factories and workshops had only natural or limited artificial lighting and no task lighting. Assessors frequently found that there was not sufficient space between materials and equipment to walk without having to step over or around objects. In some shops, workers walked or climbed over materials to go from one area to another. Floors were not kept clean of work trimmings, dust, scraps, water, or chemicals. The majority of shops had stand fans and wall or ceiling exhausts, which were inadequate to control metal and plastic fumes, smoke, or dusts to the point when visibility was sometimes affected. Where exhausts were present, they were not filtered, so fumes were released directly into the atmosphere. The limited ventilation was mostly used for personnel cooling purposes, particularly during warm months. The metal and plastic shops that MSF teams visited all had machinery with rotating or reciprocating wheels, pulleys, or belts, and few had guards in place to prevent contact or entanglement. Several types of machining, shaping, or material handling tasks positioned workers close to these moving parts. Some automated equipment required workers to reach into the moving equipment to remove the formed product or part. Workers also used hot equipment, including plastic melting and molding machines. All factories failed to provide an ergonomic working environment: workers were required to perform repetitive tasks and hold fixed postures for long periods of time. In about a third of the metal, plastic, and garment factories, workers performed some tasks above shoulder level and were often required to excessively twist, bend, or work in awkward positions. Workers from tanneries and garment, leather, and other factories were often required to hold the same position for much of their shift. Chemicals were generally stored in and dispensed from containers holding five gallons or more, and employees often poured rather than pumped chemicals. In tanneries, workers regularly walked in or were splashed with caustic or acidic water or chromate tanning solution. They often worked with bare feet and hands and were not seen to wash off the material.  Nearly all workers—like everyone in South Asia in general—wore plastic or rubber flip-flops, especially in the poorer districts. Their feet were usually unprotected from sharp or heavy objects, hot metal and plastic, sparks, and chemicals. Few workers wore fabric gloves, but most had short sleeves, short pants, and sandals. In some cases, protective gloves, boots, or aprons (some made from trash bags) were worn during the use or pouring of chemicals. However, welders, grinders, and cutters of metal and plastics were seldom seen to wear protective glasses. If glasses were used, they were usually not tinted. Assessors found that workers were unaware of the hazards of arc flash to vision. There was a similar lack of awareness of hygiene and first aid. Workers were observed eating and smoking with contaminated hands, sometimes even when washing water was available.
“A MODEL FACTORY” Following the 2017 hazard survey, MSF—with the technical support of industrial hygienist and consultant William S. Carter—developed a pilot intervention to improve working conditions in a select number of factories. Most hazards in these factories were readily observable and deemed mitigatable with inexpensive interventions. The team hoped this pilot intervention would demonstrate the feasibility of implementing interventions, generate interest in improving workplace safety in the slum factories, and promote policy change for this neglected worker population. In early 2018, MSF set out to identify work sites that could serve as “model factories” in this effort. Sixteen of the 150 previously assessed factories met the criteria for the project: they employed between 20 and 50 workers, received a poor rating on the 2017 hazard survey, and had been registered with MSF since 2014. Factory layout and owners’ consent also factored into the selection process.  MSF ultimately selected two garment factories and two recycled plastic factories for the project. One factory converted skeins of cotton yarn into bobbins and spools of thread. The second garment maker conducted screen printing of fabric and tailored the fabric into clothing. The two barrel makers used recycled post-consumer polyethylene to make barrels in sizes from 90 liters to 200 liters. MSF’s project involved three stages.  Phase one: re-assess hazards. MSF conducted a hazard and qualitative risk assessment of the four factories using an improved and extended modification of OSHA’s guidelines for safety and health programs. The three-level risk assessment used the relative risk scale, where 0–1 identifies a potential risk with little or no health risk or loss of time on the job; 2–3 identifies a risk with potential short-term loss of time on the job or potential long-term reduction in function of senses; and 4–5 identifies a potential risk that could cause severe or permanent damage to the body or potential loss of life.  Since musculoskeletal disorders were significant among these workers, MSF also selected a number of employees who performed repetitive activities to undergo a musculoskeletal evaluation using the extended version of the Nordic Musculoskeletal Questionnaire (NMQ-E) form, which can be used to evaluate musculoskeletal problems. Assessors further evaluated workers who scored high on the NMQ-E using the Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Phase two: design and implement interventions. The industrial hygienist designed, evaluated, and adjusted tailored interventions based on the findings from the first hazard assessment. These interventions were implemented accordingly, and a second hazard assessment conducted three months later evaluated their effectiveness. Phase three: measure hazard mitigation. At the nine-month mark (the time allowed for the study), a third hazard and qualitative risk assessment will determine the improvement in health and safety at the factories. A second NMQ-E will be conducted on the workers where musculoskeletal interventions have been implemented.  MAJOR HAZARDS AND INTERVENTION ACTIVITIES  The most significant hazard identified in the bobbin and spool thread company was visible cotton dust on the machines, the walls, and the floor. MSF recommended regular cleaning and housekeeping using a commercial wet/dry vacuum to prevent dust accumulation. The factory also installed increased exhaust ventilation to remove the dust, heat, and humidity. Several workers evaluated using the NMQ-E were found to be at significant risk of developing musculoskeletal disorders due to repetitive motion in awkward positions. Priority intervention activities in the second garment factory include building a containment area for the storage of the screen-printing chemicals, improving exhaust ventilation, and testing lighting levels where the tailors work using a cosine- and color-corrected light meter. MSF also recommended that the employer create more even lighting in the work environment by whitewashing the walls and installing LED panel-style lighting. Assessors conducted ergonomic evaluations of selected tailors, and MSF is evaluating the effectiveness of adjustable chairs to replace the piano-style benches and adjustment of foot pedals. (The position of the foot pedal relative to the chair dictates the potential stress on the worker’s knee, lower leg, ankle, and foot.) Low benches will provide more comfort for the workers who fold and package garments.
Woman at work in a factory that converts skeins of cotton yarn into bobbins and spools of thread. Photo credit: William S. Carter
In the barrel factories, workers are protected against heat and moving parts by newly installed machine guards on the grinders, extruders, and generators. MSF conducted modeling to identify sources of noise and intends to recommend noise controls because exposures during equipment operation exceeded 95 dBA in one factory and 105 dBA in the other. The factory owners are resistant to installing acoustical barriers or blankets, so MSF supplied ear muffs  for workers to use during operations. Polyethylene vapors are being controlled as needed with the use of LEV over the extruder. MSF’s preliminary observations indicate a more than three-fold decrease in the risk level for the screen-printing factory and a 2.2-fold decrease for the bobbin and spool thread company. The plastic factories show a 1.5-fold reduction in risk. CHALLENGES REMAIN Many factors continue to make it challenging to develop a culture of occupational health and safety awareness in areas like Kamrangirchar, where one factory owner was heard to suggest that Bangladeshi workers are “not affected by the dust.”  Time and money. Some companies base workers’ pay on a piece production rate for each employee. This means that taking time to conduct OHS activities can chip away at employee earnings. It’s necessary to reorient owners of these facilities so that workers are compensated for cleaning or conducting other OHS maintenance activities.  Use of PPE. While attempting to implement engineering controls, MSF personnel issued PPE to workers. But the use of PPE varies greatly in this region. For example, workers will wear protective gloves when handling hot plastic parts in factories. However, in one workplace where noise levels exceeded 85 dBA (ACGIH’s threshold limit value for an eight-hour time-weighted average sound level), only 14 of 36 pairs of ear muffs issued by MSF were accounted for and worn by workers. MSF also issued safety glasses, but observed few workers wearing them. Resistance to engineering controls. As previously mentioned, noise levels in the plastic factories were measured at 95 dBA and 105 dBA. The team conducted modeling to identify noise sources and methods to control noise in the factories, and recommended the installation of acoustical containment around the grinder equipment and acoustical blankets to dampen the noise of compressors. However, factory owners rejected the recommendations, even after several discussions. The owners perceived that the engineering controls would interfere with production. Lack of a consistent supply chain. The majority of products produced by these small factories is for local consumption. Unlike in the ready-made garment (RMG) industry, a major portion of Bangladesh’s export industry, small factory owners often change their methods of distribution and customers. Large factories that produce goods for the RMG industry have long-standing contracts, and purchasers apply economic pressure on the manufacturers to improve working conditions. With small factories, purchases are made on the “spot market,” in which owners often find new customers daily and the relationship between manufacturers and buyers is short term. In this situation, there is no pressure from the supply chain to change work practices. FUTURE WORK The pilot intervention was expected to be complete by first quarter 2019. MSF plans to develop further interventions and will continue working with factories to improve working conditions. Workers who present at the OH clinic with musculoskeletal disorders or complaints will be evaluated using the NMQ-E, and physicians will follow up with recommended interventions with the support of an IH. MSF is also considering audiometric testing to increase workers’ awareness of hearing loss, and is planning to conduct further training programs in ergonomics, first aid, hazard communication, and lockout/tagout.   GARY BANGS, CIH, was a consultant industrial hygienist for Médecins Sans Frontières in Bangladesh in 2016–2017. WILLIAM S. CARTER, PHD, CIH 1986–2017, was a consultant industrial hygienist for Médecins Sans Frontières in Bangladesh in 2018–2019. RASHED MD MAHFUZULLAH, MD, is an occupational health physician and medical supervisor with Médecins Sans Frontières. Send feedback to The Synergist. The authors thank the MSF team members—especially Environmental Health Officer Mahmud Imran Tulkder and Outreach Supervisor Md. Masud Kaiser—who made these projects possible. The results described in this article are a preliminary qualitative representation of gathered data. Final analyses and peer review have not been completed.
Improving OHS for Workers in Small-Scale Factories in Bangladesh

Forgotten Workers 
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Disadvantages of being unacclimatized:
  • Readily show signs of heat stress when exposed to hot environments.
  • Difficulty replacing all of the water lost in sweat.
  • Failure to replace the water lost will slow or prevent acclimatization.
Benefits of acclimatization:
  • Increased sweating efficiency (earlier onset of sweating, greater sweat production, and reduced electrolyte loss in sweat).
  • Stabilization of the circulation.
  • Work is performed with lower core temperature and heart rate.
  • Increased skin blood flow at a given core temperature.
Acclimatization plan:
  • Gradually increase exposure time in hot environmental conditions over a period of 7 to 14 days.
  • For new workers, the schedule should be no more than 20% of the usual duration of work in the hot environment on day 1 and a no more than 20% increase on each additional day.
  • For workers who have had previous experience with the job, the acclimatization regimen should be no more than 50% of the usual duration of work in the hot environment on day 1, 60% on day 2, 80% on day 3, and 100% on day 4.
  • The time required for non–physically fit individuals to develop acclimatization is about 50% greater than for the physically fit.
Level of acclimatization:
  • Relative to the initial level of physical fitness and the total heat stress experienced by the individual.
Maintaining acclimatization:
  • Can be maintained for a few days of non-heat exposure.
  • Absence from work in the heat for a week or more results in a significant loss in the beneficial adaptations leading to an increase likelihood of acute dehydration, illness, or fatigue.
  • Can be regained in 2 to 3 days upon return to a hot job.
  • Appears to be better maintained by those who are physically fit.
  • Seasonal shifts in temperatures may result in difficulties.
  • Working in hot, humid environments provides adaptive benefits that also apply in hot, desert environments, and vice versa.
  • Air conditioning will not affect acclimatization.
Acclimatization in Workers