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To the Editor:
The occupational health of immigrants has received increased attention in recent years. The urban car wash industry in the United States is a prototypic highly competitive immigrant-dominated sector characterized by small businesses. Few occupational health studies of the industry have been published,1–6 because the work force is divided among separate businesses with relatively few workers at each car wash, and access to its low wage immigrant work force for research is challenging. In addition, the familiarity of the industrial process to car wash consumers and to occupational health researchers may ironically lead to underestimation of its occupational risks.
The car wash industry, however, has salient features that predispose to important occupational health risks, namely, the use of hazardous chemicals (ie, hydrofluoric acid), the requirement of repetitive use of extremities, close contact with moving machinery, an economically vulnerable immigrant work force, a competitive business environment, and a lack of regulations and oversight of workplace practices.
According to US Census data, there were 16,166 car wash establishments (NAICS 811192) and 160,018 paid car wash employees in 2016. In New York City alone, there are 2673 car wash workers in 242 car washes.7 Working conditions in urban car washes have come under increased scrutiny in recent years, focusing principally on wage issues and, to a lesser extent, workplace safety. In a 2014 report by the Retail, Wholesale and Department Store Union (available from authors), an analysis of OSHA data from 38 New York City car wash inspections conducted from 2008 through 2013 found that nearly all inspections resulted in serious violations with a mean of 2.5 such violations per facility.
In collaboration with a labor union (Retail, Wholesale and Department Store Union, RWDSU) and two community-based organizations (Make the Road New York, and New York Communities for Change), we conducted an anonymous, voluntary survey on a convenience sample of car wash workers from seven New York City car washes in 2016 and 2017. Surveys were conducted in English or Spanish, with most (n = 63) of the 70 interviews conducted in Spanish by trained Spanish-speaking interviewers. The interview questions addressed demographics, history of car wash work, job tasks, health symptoms during the past 12 months, self-reported history of asthma, health care utilization, availability and use of personal protective equipment, and workplace training. All questions were drafted collaboratively by the academic study partner with input from personnel of the union and community organizations. All but one of the seven car washes were represented in labor contracts by RWDSU at the time the surveys were conducted; most of the contracts were initiated within 2 years prior to the survey. The survey was conducted in the car washes or in community facilities or retail settings near the car washes at the end of work shifts. The City University of New York Institutional Review Board reviewed and approved the project, waiving the need for written consent.
We interviewed 70 male workers from seven New York City car washes, representing approximately one-half of the estimated worker population employed at the worksites included in the study, which each ranged from 33 to seven workers. Workers had a mean age of 38.6 years and were mostly Spanish-speaking Latinos, with 66 participants (94%) reporting being born outside of the United States (Table 1). The study population was a stable full-time work force with nearly one-half (46%) employed more than 5 years in the car wash industry. Participants worked long hours with nearly one-half (43%) employed 6 days per week, and working on average 10.1 hours per day (standard deviation [sd] = 1.8) (Table 1). Most participants rotated among the few major tasks at the car wash, including drying cars (63%), brushing and soaping cars (56%), and vacuuming and cleaning cars (50%).
Car wash workers reported a high prevalence of health symptoms during the 12 months prior to the survey, including at least one site of musculoskeletal pain (80%); upper airway, eye, or skin irritation (71%); and at least one lower respiratory symptom (47%) (Table 2). Approximately one-half of all workers reported eye and throat irritation, back pain, neck or shoulder pain, hand pain, headaches, or nausea/stomach discomfort. The majority of workers reported multiple symptoms across the different symptoms groups. Thirty-eight (54%) participants reported two or more musculoskeletal symptoms in the past 12 months, and 37 (53%) reported two or more types of irritation (nose bleeds, throat irritation, eye irritation/burning, skin rash, or skin burn). Two workers had suffered fractures at work in the past 12 months, and one-quarter of the work force reported a laceration or abrasion of the skin. Three workers reported an episode of asthma or an asthma attack in the past 12 months.
Nearly 60% of car wash workers (n = 41) ascribed one or more health problems to their work in the past 12 months. The most common individual symptoms attributed to work were back pain, eye irritation, shortness of breath, headaches, and upper extremity pain.
One in seven surveyed car wash workers (n = 10) reported being injured at work in the past 12 months, and one-fifth (n = 14) reported that a coworker was injured at work. These were mainly hand or finger injuries, including lacerations, fractures, or jams due to machine inflicted trauma (including equipment and car doors). Over 40% of participants (n = 29) had seen a doctor or health care provider in the last 12 months. About one-half of these visits were associated with the symptoms described above.
Car wash workers were uncommonly provided with any personal protective equipment except for gloves. One-half (56%) of participants reported receiving any type of gloves at work (Table 3). When the employer provided gloves, the primary glove types provided were latex-coated short (to the wrist) cotton gloves (n = 17), followed by nitrile gloves (n = 15). Many workers supplied their own gloves, contributing to the nearly three-quarters of participants who reported wearing gloves when needed for at least 50% of their work time. Other types of personal protective equipment were uncommonly provided and rarely used (Table 3). Principal reasons cited for not using personal protective equipment (PPE), when available, included, in descending order of frequency, that the PPE: (a) was not comfortable, (b) did not work well, (c) was not needed, (d) was not clean, (e) did not fit properly, or (f) was used by too many other workers. Virtually all participants (93%) reported they had not been provided with any safety training by their current employer in the past 12 months.
Car washes are urban assembly lines that employ toxic chemicals handled by untrained and unprotected immigrant workers who perform highly repetitive movements to produce clean vehicles. The largely Latino male work force is stable and hard-working—frequently working 60 hours per week, which reflects in part low wages and the workers’ lack of alternative employment options.
The frequent irritant and respiratory symptoms reported by car wash workers are typical of those commonly associated with the cleaning agents they use, especially when few controls or protections are in place. Their high prevalence of musculoskeletal symptoms reflect the strenuous ergonomic challenges experienced by this worker population, such as spending long hours standing, twisting their trunks, and moving their extremities repeatedly in highly stereotypic movements. Given the frequency and proximity of use of toxic cleaning agents and the frequency and duration of their repetitive movements, it was somewhat surprising that more workers did not attribute their musculoskeletal pain and irritant symptoms to work. This finding may be due to the lack of knowledge about occupational hazards, given the absence of any occupational health training at car washes. Notably for a workplace where large machines are constantly moving, trauma was common, though less so than the health symptoms reported above. That two of 70 workers had a bone fracture during the past 12-month period demonstrates a significant problem.
Limitations of the survey included 50% participation rate among the estimated work force of the car washes studied, self-reporting of health conditions, and lack of industrial and safety inspections of the car washes. The lack of medical verification of the reported health problems limits identification of specific illnesses, but the symptoms reported closely match the expected health outcomes associated with car wash exposures, making work-relatedness highly likely. The lack of onsite safety assessments at the car washes limits a full understanding of the work environment, but the transparency of the worksite to car wash customers (and researchers) provides an unusual degree of ready comprehension of the worksite. Although we only surveyed unionized car washes, they had only been recently unionized, so health and safety conditions were unlikely to be very different from non-unionized car washes. Priorities of the recently negotiated union contracts focused initially on wages and benefits, while background knowledge about car wash health and safety conditions was being collected for future interventions.
The car washes in this study place the adequate protection of their workers at low priority, as illustrated by the reported lack of personal protective equipment and by the lack of providing education or training about on the job hazards and their control. Rotating job tasks, that is, a means of administrative control, is the only employed method of controlling exposures. However, it is ineffective, since many workers still report symptoms characteristic of the hazards of car wash environments. The latex-coated gloves, reportedly used at these car washes, are inadequate for car wash work, because they do not adequately prevent skin absorption through the glove material, and, moreover, offer limited skin coverage, as most of the gloves used extended only to the wrist. Another high risk task, is of cleaning the cistern—a specialized task that provides an opportunity for exposure to highly concentrated chemical agents. This task was uncommonly associated with provision of any protective equipment.
Improvements in the occupational health conditions at car washes can be readily achieved through use of the least toxic cleaners; provision of appropriate, effective, and acceptable PPE and their storage; and adequate training of workers as part of a comprehensive occupational health and safety program for car wash workers. Addressing ergonomic conditions and minimizing respiratory exposures are more challenging problems and require further study and consideration. Most importantly, recognizing that occupational health risks cannot be addressed in isolation but are embedded in a universe of difficult work and social conditions for these low wage immigrant workers is key to protecting their health and welfare.
The authors thank Make the Road New York, New York Communities for Change, and the Retail, Wholesale and Department Store Union for developing the idea for the study, providing access to the work force, and assisting in questionnaire development and in results interpretation; and Javier Gallardo, Zulleyka Ortega, and Gladys Palaguachi for assisting in the interviews and providing general support of the study.