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.