Working Conditions of Chagas' Disease Patients in a Large Brazilian City

Situação trabalhista do portador de doença de Chagas crônica, em um grande centro urbano 1 Grupo de Estudos em Doença de C hagas, De p a rtamento de Clínica M é d i c a , Faculdade de C iências Médicas, Un i versidade Estadu al de Ca m p i n a s. Abstract This study evaluated the working conditions of Chagas' disease patients in the city of Ca m p i n a s , São Pa u l o, focusing on two-hundred-fifty patients with steady employment and t reated at the Un i versity Hospital (HC-FCM/Un i c a m p) : 98% were working-age and 77.6% were m e n. The origin of the patients reflected the migra t o ry process occurring among this population. Most of the patients had limited professional skills, while 63.6% had not finished primary school and 21.6% were illitera t e. How e ve r, 63.6% were re g u l a rly employed under duly processed work c o n t ra c t s. Their jobs were mainly in general services (21.6%) and heavy industry (21.2%). S o m e 55% of the patients re p o rted a monthly income less than or equal to U$100.00, and 40.4% rep o rted having been fired at least once during the last ten years, in 8.9% of the cases because of a diagnosis of Chagas' d i s e a s e. Of the patients undergoing pre-hiring physical ex a m i n a t i o n s (5 7. 2 %) , 9.1% were re f u s e d , 92.3% of whom due to positive sero l o gy for T. c r u z i. Fi n a l l y, 78.4% rep o rted not belonging to a labor union. The study demonstrated the precarious working conditions and discrimination experienced by workers with Chagas' d i s e a s e. Palavras-chave Do e nça de Chagas; Try p an os oma cru z i; Saúde Ur b a n a ; Tra b a l h a d o re s


I n t ro d u c t i o n
Most of the initial studies on pre valence of C h a g a s' disease in Brazil we re carried out in endemic are a s.Studies on the pre valence of Trypanosoma cruzi infection in urban areas are m o re recent: Goldbaum (1976) detected a p re valence of 4.9% in a population of migrants living in São Pa u l o, and Litvoc (1977) estimated a p re valence of 7.7% among migrants in the municipality of São Pa u l o.Howe ve r, on the basis of a nationwide serological survey from 1975 to 1981, pre valence of T. c r u z i infection for Bra z i l as a whole has been estimated at about 4.2% ( Cam a rgo et al., 1984).
In the municipality of Ca m p i n a s, São Pa u l o St a t e, a pre valence of 2% positive serology for T. c r u z i was detected in 1988 among blood donors ( D. San Ma rtini, M. V. F. Ca m i l o, L. L. Ta k a h a s h i , personal communication).On the basis of this result, the number of Chagas' disease patients in the municipality and surrounding area, including approximately 2 million inhabitants, is estimated at 40 thousand, 10 thousand of w h o m a re assumed to be work e r s, since 25% of the local population is actively engaged in the labor m a rket (FIBGE, 1992).
Based on the large number of individuals with T. c r u z i infection in a non-endemic are a and occupational health considerations for w o rkers with chronic Chagas' disease (Co u ra , 1966;Po rt o, 1974;Ca n ç a d o, 1987;Luquetti & Po rt o, 1997), especially in the secondary and t e rt i a ry sectors of the economy which pre d o minate in the city of Campinas and the surro u n ding area (NEPP, 1987), the goals of this study we re to evaluate the conditions of workers w i t h c h ronic Chagas' disease and identify potential discrimination associated with positive s e ro l o g y.

M e t h o d o l o g y
The re s e a rch used a survey of 250 cases, with the population of patients infected by T. c r u z i being re s t ricted to the Chagas' Disease Ou t p atient Se rvice (GEDoCh) of the Un i versity Ho spital under the School of Medical Sciences, State Un i versity of Ca m p i n a s, the only serv i c e in the municipality providing specific care for C h a g a s' disease patients re g a rdless of the clinical form or stage of the disease.Each individual diagnosis was confirmed by two or more s e rological tests with positive re s u l t s.All interv i e wees we re informed about the re s e a rch protocol before enrolling in the study, perf o rm e d under guidelines established by the De c l a ra-tion of Helsinki (British Medical Association, 1 9 6 4 ) .
The inclusion cri t e rion for Chagas' disease patients in the study was their work re l a t i o ns h i p, i.e., individuals whose present or past occupation was related to the formal or inform a l labor market.T h u s, minors, housewive s, and students we re excluded from the study.
The instrument used for the study was a coded questionnaire requesting the follow i n g data: age bracket, sex, place of birth, schooling, mode of participation in the work market, are a of work, salary, number of and reasons for dismissals over the last ten ye a r s, attitude tow a rd s dismissal, pre -h i ring physical examination, refusal and reason for refusal after pre -h i ri n g physical, and trade union membership.
T. c r u z i-i n f e c t e d / C h a g a s' disease work e r s we re clinically classified as follows: 1) indeterminate form (IF), or individuals with no abnormal findings in the physical examination, chest x -ra y s, electro c a rd i o g ram, or esophageal and colonic x-rays and 2) individuals with manifestations of Chagas' disease (CD).The re s u l t s f rom IF and CD we re compared for all data with the aid of χ 2 test (p<0.05).
Data on the socioeconomic development of the municipality of Campinas we re supplied by the Municipal Planning and Co o rdination Se cre t a riat (Seplan) and the Institute of Ec o n o mics at the State Un i versity of Ca m p i n a s.

R e s u l t s
The 250 workers enrolled in the study we re classified as follows: 143 in the IF group ( 5 7 .1 % ) and 107 in the CD group (42.9%).
The Evaluation of the number of dismissals ( Table 3) per worker over the last 10 ye a r s s h owed that 149 patients or 59.6% (85 IF, 57.1%; 64 CD, 42.9%) we re stable on the job as opposed to 101 workers or 40.4% (58 IF, 57.4%; 43 CD, 42.6%) who had been fired at least once, with a predominance of dismissals with no justification (54 individuals, or 53.5%).Eva l u a t i o n of the work e r s' attitudes tow a rds dismissals s h owed that 80 patients (79.2%) had taken no m e a s u res to challenge the dismissal, while only 16 (15.8%)re p o rted have turned to the tra d e union for re d re s s.
Pre -h i ring physicals had been given to 143 individuals (57.2%): 89 IF, or 62.2%, and 54 CD, or 37.8%, as opposed to 107 individuals ( 4 2 .8 % ) who had not re c e i ved a physical: 54 IF, or 5 0 .5 % , and 53 CD, or 49.5%.Of the 13 individuals (7 I F, 53.9%; 6 CD, 46.1%) who we re refused ( 9 . 1 % of those who re p o rted having had a pre -h i ring physical), 92.3% attributed this re f u s a l to positive serology for T. c r u z i i n f e c t i o n ( Table 4).Fi n a l l y, only 13.6% of the workers re p o rt e d belonging to a trade union, as opposed to 78.4% who did not participate in any such labor org an i z a t i o n .

D i s c u s s i o n
The social dimensions of Chagas' disease in the Brazilian historical context suggest that pre d at o ry settlement of the country generated both i r rational exploitation of re s o u rces and continuous and pro g re s s i ve deforestation, thus causing ecological imbalance and shifting Chagas' disease vectors from their wild habitats, with the resulting infestation of triatomines in and a round human dwe l l i n g s.This form of colonization invo l ved the construction of "w a t t l e" houses in ru ral are a s.Such dwellings foster domiciliation of tri a t o m i n e s, thus facilitating the natural transmission of Chagas' disease ( Ba r re t o, 1979; Briceño-León, 1990).
In addition, in the industri a l l y-based Bra z i lian development model, especially in the Southeast, an intensive migra t o ry process has invo l ved large portions of the underpri v i l e g e d population in the search for better living and w o rking conditions, including individuals fro m endemic areas for T. c r u z i infection.Ac c o rd i n g to Dias & Dias (1979), there is a trend tow a rd s "u r b a n i z a t i o n" of Chagas' disease as a consequence of the country 's economic model, with a concentration of migrants on the outskirts of l a rge cities.This gives rise to the social pro blem of a large number of Chagas' disease patients who have left the poorer ru ral areas for the cities and established a well-defined social situation by joining the capitalist pro d u c t i o n system (Goldbaum, 1976(Goldbaum, , 1981 Because of the disease's pathophysiological c h a ra c t e ri s t i c s, especially cardiac invo l ve m e n t ( L a ranja et al., 1956;Andrade & Andra d e, 1979), individuals with Chagas' disease may face exclusion from the labor market during the hiring pro c e s s, lack of adaptation to pro f e s s i o n a l a c t i v i t i e s, and summary dismissal, since Bra z i lian law allows for dismissal with no prior justification (Brasil, 1981).Subsequent formal pro o f of such dismissals thus becomes difficult.Although the litera t u re suggests the disease's dire p s ychosocial impact (Dias & Di a s, 1979;Pe t a n a , 1980;St o rino & Milei, 1986), little inform a t i o n is available concerning possible on-the-job d i s c rimination against chronic Chagas' disease p a t i e n t s.
In the current study we interv i e wed 250 C h a g a s' disease patients with steady work and found age to be a social indicator for analysis of T. c r u z i-infected work e r s.Most of the workers we re in their pro d u c t i ve ye a r s.It should be pointed out that only 2% of the interv i e we e s did not belong to the economically active population which, according to the Brazilian In s t itute of Ge o g raphy and Statistics (FIBGE, 1985), includes the 15-65-year bracket.Se ve n t y-s i x p e rcent of the individuals interv i e wed we re m a l e s, a concentration justified by the design of the investigation which excluded individuals without a well-defined work re l a t i o n s h i p, a situation much more frequent among women.T h e re we re pro p o rtionally more individuals classified in the indeterminate form of Chagas' disease among men as compared to women.This probably reflected male work e r s' earlier diagnosis and easier access to a re f e rence clin- Refusal and reason for refusal after pre-hiring physical examination.The origin of the workers interv i e wed conf i rmed the marked migra t o ry process experienced by this population, as well as the dire ction of this flow tow a rds Campinas and the surrounding region from areas endemic for Chag a s' disease.In addition, the low educational l e vel of the sample population allowed us to infer the low professional skills of these individua l s, a fact that certainly contributed to their poor wages and unstable work situation.Less education was associated with more seve re c a rdiac damage from T. c r u z i infection, a re s u l t that highlights the pre c a rious conditions of w o rkers with Chagas' disease.
From a social perspective, another chara ct e ristic of this population is its mode of part i c ipation in the economy.When occupation was s u rve yed in the present study (Table 1), a high p e rcentage of workers we re found to belong to the formal labor market, a fact probably due in p a rt to pre s s u re by re p re s e n t a t i ve org a n i z ations (unions) which are quite active in Ca m pinas and the surrounding region.Howe ve r, the c a rdiac form of the disease was most common in workers with Chagas' disease who had unstable work .
Di s t ribution of the work force was associated with the re g i o n's deve l o p m e n t -c e n t e re d p ro f i l e, still maintaining an important link to the ru ral area because of food pro d u c t i o n .
Wages are an indicator of life style for the study sample.The re f e rence used here was the minimum monthly wage.Some 45.6% of interv i e wees re p o rted earning one to two times the monthly minimum wage, and a full 9.6% rep o rted earning less than one minimum monthly wage.In the last group (< 1 minimum wage), the majority of workers with Chagas' disease, or 79.2% of the individuals in this category, had the cardiac form of the disease ( Table 2), i n d icating that worse living conditions we re associated with higher morbidity.Co n s i d e ri n g that purchasing power of Brazilian wages has d ec reased considerably over the last decade ( N E P P, 1987), one can easily infer Chagas' disease work e r s' level of impove rishment and the related disastrous social consequences.
With re g a rd to job stability (Table 3), 40.4% of the workers had been fired at least once in ten ye a r s.No difference was observed betwe e n w o rkers with IF and CD.Causes of firing we re d e s c ribed as dismissal with no justification, a s t rategy that may "d i s g u i s e" possible work e r d i s c rimination linked to the individual having C h a g a s' disease.A full 8.9% of the workers re-p o rted having been fired explicitly because of their disease.Fo l l owing dismissal, most of the w o rkers (80, or 79.2%) re p o rted having made no claims to re d ress for breach of their labor c o n t ract.The interv i e wees expressed misgivings and lack of information about how to appeal or exercise their ri g h t s.Only 16 (15.8%)had contacted the union, and four (4%) had contacted the Regional Labor Office.
Of those undergoing pre -h i ring physicals, 9.1% we re refused for the job, and 92.3% of these refusals we re due to positive serology for T. c r u z i, confirming the suspected discri m i n at o ry attitude in the hiring pro c e s s, not associated with the clinical presentation of the disease (Table 4).The study also addressed part i cipation in some type of labor union; 78.4% of the workers with Chagas' disease re p o rted not belonging to a union, implying absence of worker defense and strategies to guarantee labor ri g h t s.

C o n c l u s i o n s
The results of this study on individuals with T. c r u z i infection in a large Brazilian city indicate d i s c rimination against people with Chagas' disease in the labor market.T h e re was a high rejection rate associated with positive sero l o g y for T. c r u z i among job candidates refused after p re -h i ring physicals.Se rological diagnosis of the disease was also re p o rted as a justification for dismissal, re g a rdless of the work e r s' clinical c o n d i t i o n .
We also observed possible "c ove r-u p" of dismissals without just cause.The pre c a ri o u s labor situation of patients with T. c r u z i i n f e ction was confirmed, particularly for those with m o re seve re clinical evidence of Chagas' dise a s e.Most of the workers are from economically depressed areas with a deficient social infras t ru c t u re and have limited schooling and thus l ow professional skills, earning low wages and e x p e riencing job instability, thus leaving them p rone to job discrimination and dismissal on the basis of their positive serological status.
' disease because of their part i c ipation in the production process (Orosz et al., 1 9 9 6 ) .
ing from the interior of the State of São Pa u l o : 48 (58.5%) in the IF group and 37 (41.5%) in the CD gro u p.Another 96 (38.2%) we re from the State of Minas Ge rais: 53 (52.2%) classified in the IF group and 43 (47.8%) in the CD gro u p.Other locations we re re p o rted by 27.3% of the i n t e rv i e we e s, with no difference in distri b u t i o n of clinical pre s e n t a t i o n .As for educational level, 69% of the interv i e wees or 174 patients (106 IF, or 61.6%; 66 C D, or 38.4%) stated having an incomplete prim a ry education (the first eight years of s c h o o l ) , while 11 individuals or 5% (8 IF, 72.8%; 3 CD, 27.3%) had completed pri m a ry school.T h e g roup immediately following consisted of illite rates (54, or 22%): 22 (40.7%) in the IF gro u p and 32 (59.3%) in the CD gro u p.Only 5 (2%) of the Chagas' disease workers re p o rted having re c e i ved a complete or incomplete high school education: 4 IF, 80%; 1 CD, 20%.The re m a i ning levels we re re p o rted by 6 patients: 2 IF, 33.3%; 4 CD, 66.7%.Level of schooling was statistically significant for the two clinical f o rm s.In terms of occupation or participation in the economy (Table1), 175 individuals (70%), including 117 IF (66.8%) and 58 CD (33.2%), stated that they we re regularly employed, foll owed by 36 patients (14.4%) who had re t i re d due to disability or we re on sick pay.

Table 1
Mode of participation in the labor economy and work are a .

Table 3
Number and causes of dismissals in last ten years.