COMPUTERS AND HEALTH-- INDIVIDUAL AND lNSTITUTIONAL PROTECTIVE MEASURES ================================================ by Daniel A. Updegrove and Kimberly H. Updegrove Within the past two years, substantial media attention has been directed at potential adverse health effects of long-term computer use. Renewed concerns about radiation, combined with reports of newly-recognized "repetitive stress injuries" such as carpal tunnel syndrome, have led some to call for regulation in the workplace and others to rearrange their offices and computer labs. There is little evidence that computer use is on the decline, however. On the contrary, more people are spending more time doing more tasks with computers -- and faculty, students and staff at colleges and universities have some of the most computer-intensive work styles in the world. If, as is widely suspected, health effects are cumulative, then many of us are at risk in our offices, labs, dormitories, and homes. Unfortunately, many years will be required before epidemiological studies can provide definitive guidelines for computer users, managers, furniture suppliers, and office designers. In the interim, individuals and institutions must educate themselves about these issues and protective measures. One set of issues concerns workstation design, setup, and illumination, together with users' work habits. The City of San Francisco, which recently enacted worker safety legislation, cited research by the National Institute of Occupational Safety and Health (NIOSH) into VDT operator complaints of eyestrain, headaches, general malaise, and other visual and musculoskeletal problems as the rationale for imposing workplace standards, to be phased in over the next four years. A second set of issues relates to suspected radiation hazards, including miscarriage and cancer. A special concern with radiation is that nearby colleagues could be affected as well, since radiation is emitted from the backs and sides of some terminals. The most recent NIOSH study is reassuring, but some caution still seems prudent. Ergonomics and work habits ========================== Most people can ride any bicycle on flat ground for a short distance with no problems. On a fifty mile ride over hilly terrain, however, minor adjustments in seat height, handlebar angle, and the like can mean the difference between top performance and severe pain. Similarly, occasional computer users may notice no ill effects from poorly designed or badly adjusted workstations, whereas those who spend several hours a day for many years should pay careful attention to ergonomics, the study of man-machine interfaces. The key to most workstation comfort guidelines is adjustability--to accommodate different body dimensions, personal workstyle preferences, and the need to change positions to avoid fatigue. A recommended working posture shows the body directly facing the keyboard and terminal, back straight, feet flat on the floor, eyes aligned at or slightly below the top of the screen, and thighs, forearms, wrists, and hands roughly parallel to the floor. Achieving this posture may require: * A chair with a seat pan that adjusts both vertically and fore-and- aft, an adjustable height backrest, and adjustable tilting tension * An adjustable height work surface or separate keyboard/mouse tray (note that many keyboard trays are too narrow to accommodate a mouse pad, leaving the mouse at an awkward height or reach on the desktop) * A height adjustment for the video display (a good use for those manuals you'll never read!) * An adjustable document holder to minimize head movement and eyestrain * Adjustable foot rests, arms rests, and/or wrist rests. Studies show that many people are unaware of the range of adjustments possible in their chairs and workstations. Although the best chairs permit adjustment while seated, you may have to turn the chair upside down to read the instructions. (Be careful not to strain your back while upending and righting the chair!) If your posture deviates substantially from that in the diagram--or if you are experiencing discomfort-- experiment with adjustments or try exchanging chairs or workstations with colleagues. A posture cushion, which maintains the natural curvature of the spine and pelvis while supporting the lumbar region, may also prove helpful. It should be noted that any adjustment may feel uncomfortable for a week or so while your body readjusts itself. (Some people have been advised by their physicians to use a backless "Balans" chair, which minimizes compression of the spine and shifts the body weight forward with the aid of a shin rest. This posture may be uncomfortable, however, since it requires stronger abdominal and leg muscles than conventional sitting positions. The Balans chair is not recommended for overweight or exceptionally tall persons.) Light and glare =============== Eyestrain, headaches, and impaired vision are often a product of improper illumination resulting in glare, which is light within the field of vision that is brighter than other objects to which the eyes are adapted. Both direct glare from sunlight and lighting fixtures directed at the user's eyes and indirect glare due to reflections from video screens or glossy surfaces are common problems for VDT users. Many offices are too bright for computer use, which may be a carryover from the days when paperwork required such brightness or the result of many office workers' preferences for sunlight and open windows. A NIOSH study recommends 200-500 lux for general office work; other sources suggest 500-700 lux for light characters on dark monitors and somewhat more for dark-on-light. If documents are not sufficiently illuminated, desk lights are recommended in preference to ceiling lights, which increase reflections from video screens. Reducing overhead lighting could also result in substantial energy savings. VDT workstation placement is also important. Terminal screens should be positioned at right angles to windows, so sunlight is neither directly behind the monitor nor behind the operator, where it will reflect off the screen. If this is infeasible, blinds or drapes should be installed. Screens should also be positioned between rows of overhead fixtures, which can be fitted with baffles or parabolic louvers to project light downward rather than horizontally into the eyes or terminal screens. Some users have found filters placed in front of the screen to be effective in reducing reflections, however some dimming or blurring of the display may result. Experts advise trial and error, since the best solution appears to depend upon specific conditions and user preferences. Finally, if you wear glasses or contact lenses, be sure your physician is aware of the amount of terminal work you do; special lenses are sometimes necessary. Bifocals, in particular, are not recommended for extensive terminal work, since the unnatural neck position compresses the cervical vertebrae.. Breaks and exercises ==================== Working in the same position for too long causes tension buildup and is thought to increase the risk of repetitive motion injuries, such as carpal tunnel syndrome. Remedies include changing postures frequently, performing other work interspersed with computing (some studies recommend a 10-15 minute break from the keyboard every hour), and doing exercises such as tightening and releasing fists and rotating arms and hands to increase circulation. Be aware, also, that the extra stress created by deadline pressure exacerbates the effects of long hours at the computer. Radiation hazards ================= For at least a decade, concerns have been raised about possible effects of radiation from video display terminals, including cancer and miscarriages. Earlier fears about ionizing radiation, such as X rays, have been laid to rest, since these rays are blocked by modern glass screens. Also well below exposure standards are ultraviolet, infrared, and ultrasound radiation. More recent controversy surrounds very low frequency (VLF) and extremely low frequency (ELF) electromagnetic radiation produced by video displays' horizontal and vertical deflection circuits, respectively. Researchers have reported a number of ways that electromagnetic fields can affect biological functions, including changes in hormone levels, alterations in binding of ions to cell membranes, and modification of biochemical processes inside the cell. It is not clear, however, whether these biological effects translate into health effects. Several epidemiological studies have found a correlation between VDT use and adverse pregnancy outcomes, whereas other studies found no effect. The most recent analysis, published this year by NIOSH, found no increased risk of spontaneous abortions associated with VDT use and exposure to electromagnetic fields in a survey of 2,430 telephone operators. This study, which measured actual electromagnetic field strength rather than relying on retrospective estimates, seems the most trustworthy to date. The authors note, however, that they surveyed only women between 18 and 33 years of age and did not address physical or psychological stress factors. A 1990 Macworld article by noted industry critic, Paul Brodeur, proposed that users maintain the following distances to minimize VLF and ELF exposure: * 28 inches or more from the video screen * 48 inches or more from the sides and backs of any VDTs. Although these guidelines seem overly cautious, a fundamental principle is that magnetic field strength diminishes rapidly with distance. Users could, for example, select fonts with larger point sizes to permit working farther from the screen. Remember that magnetic fields penetrate walls. Over-reaction to ELF and VLF radiation can also compromise ergonomics. In a campus computer lab, for example, all displays and keyboards were angled thirty degrees from the front of desktops to reduce the radiation exposure of students behind the machines. The risks of poor working posture in this case appear to be greater than the radiation risks. A final form of radiation, static electric, can cause discomfort by bombarding the user with ions that attract dust particles, leading to eye and skin irritations. Anti-static pads, increasing humidity, and grounded glare screens are effective remedies for these symptoms. The institutional response ========================== Colleges and universities are starting to take these issues seriously, judging from coverage in representative campus computing newsletters. Harder to assess is whether anything on these campuses is changing. Indeed, campuses have some some particularly thorny problems: * Resources are tight, and workplace modification expenses are not tax- deductible. * Many academics resist standards and guidelines from "the administration." * A spartan ethic prevails on many campuses, leading some to reject modern, ergonomically-appropriate furnishings as too "fancy" or self- aggrandizing. * Some granting agencies provide funding for hardware and software, but exclude renovations and furnishings. * When funds are available, many of our colleagues spend willingly on MIPS and megabytes, but not on furnishing. One northeastern university dean, asked to support high-quality chairs in computer labs, replied, "Let them sit on logs." * Most dormitory and computer lab furniture is purchased for durability, not ergonomics; moreover, the same furniture must accommodate a petite freshman and a varsity football player. Management support for addressing such concerns would presumably be forthcoming if reliable studies documented linkages between badly- designed computing environments and productivity, error rates, absenteeism, health insurance and workers compensation claims, and turnover. Unfortunately, such studies are unavailable, so much policy debate continues to be based on anecdotal evidence. There are, nevertheless, several things institutions can do. Education and training ---------------------- Given the number and variety of computer users on the typical campus, and the turnover of faculty, staff, and students, we face a formidable challenge in making our colleagues aware of these issues and protective measures. Moreover, our education and training programs must target not only users but also user services staff, computer store personnel, purchasing agents for both computers and furniture, facilities planners, computer lab managers, librarians, MIS and data entry managers, scientists, departmental business administrators -- and senior management. Our approaches to education and training should be as creative as our community is diverse. Among the options we are considering at the University of Pennsylvania are the campus computing newsletter, purchasing newsletters, the campus newsweekly, employee orientation programs, brochures stuffed in new computer boxes, printed and on-line policy and procedures manuals, computer fairs, office product fairs, health fairs, and "try before you buy" demonstration facilities in cooperation with furniture and computer vendors. More informed purchasing ------------------------ It is essential that all personnel who participate in purchasing decisions be well informed about appropriate products for computer work. If your furniture vendor has never heard of a mouse, you will have difficulty building an office environment that can accommodate a Macintosh, Windows 3.0, or a UNIX workstation. If facilities planners and lab managers are unaware of lighting guidelines, too many screens will be parallel to, rather than perpendicular to windows. If no one in the purchasing department asks any questions, users will be surprised when their extended keyboards and two-page monitors don't fit on any horizontal surface in their offices. Both the purchasing department and the on-campus computer retail store should participate in efforts to inform purchasers, make available sound and cost-effective products -- and avoid the predictable rash of dubious gadgets touting "ergonomic" benefits. One other area, home furnishing for faculty, staff, and off-campus students, poses special problems: how can institutional guidance -- and discounts -- be extended on behalf of those members of the campus community spending personal funds to equip and furnish their home offices? A continuing process ==================== Massive computerization of offices, laboratories, dormitories, and homes represents a fundamental change in the way many of us work and communicate. It would be surprising if there were no adverse effects from such profound changes. It would also be surprising if all policy debates were based on sound scientific evidence, rather than parochial politics and media exposes. But, as University of Pennsylvania bioengineering professor Kenneth Foster has written, "One difficulty is that 'safety,' if considered to be the absence of increased risk, can never be demonstrated. A hazard can be shown to exist; absence of hazard cannot." To monitor research and develop institutional guidelines, the University of Pennsylvania has created a Task Force on Computing in the Workplace, with representatives from the Offices of Environmental Health and Safety, Fire and Occupational Safety, Information Systems and Computing, Radiation Safety, Purchasing, University Life as well as staff and faculty from the Wharton School and Schools of Engineering, Medicine and Nursing. Interested readers are welcome to contact the authors for information on the Task Force and its work. Until more conclusive research becomes available, individuals, departments, and institutions will have to weigh the evidence and make their own decisions about protective measures to minimize the risks of computing. And, in our opinion, the information technology managers and their vendor partners who provided the leadership to computerize our campuses, now owe it to their colleagues to work with epidemiology and ergonomics experts to create computer-intensive environments that are both productive and healthful. For further information: ======================== Branscum, Deborah. "Toward healthier computing." Macworld. August 1991, pp. 67-76. Brodeur, Paul. "Annals of radiation: The hazards of electromagnetic fields." The New Yorker. Three part series: June 12, 1989, pp. 51-88; June 19, 1989, pp. 47-73; June 26, 1989, pp. 39-68. Brodeur, Paul. Currents of Death: Power lines, computer terminals, and the attempt to cover up their threat to your health. New York: Simon and Shuster. 1989. Brodeur, Paul. "The magnetic field menace." Macworld. July 1990, pp. 136-45. City of San Francisco. Municipal Code, Chapter 5 (Health Code), Article 23, as amended. December 10, 1990. Foster, Kenneth R. "The VDT debate." American Scientist, March-April 1986, pp. 63-68. Lewis, Peter H. "Are computer safety laws taking the right track?" The New York Times, January 6, 1991, p. F8. Hembree, Diana. "Warning: Computing can be hazardous to your health." Macworld, January 1990, pp. 150-57. Morgan, M. Granger. "Expose treatment confounds understanding of a serious public-health issue." [review of Brodeur] Scientific American. April 1990, pp. 118-23. Murray, W.E. "Video display terminals: Radiation issues." Library Hi Tech 12, 1985, pp. 43-47. Pool, Robert. "Electromagnetic fields: The biological evidence." Science, Sept. 21, 1990, pp. 1378-81. Schliefer, L.M. and S.L. Sauter. "Controlling glare problems in the VDT work environment." Library Hi Tech 12, 1985, pp. 21-25. Schnorr, T.M. "The NIOSH study of reproductive outcomes among video display terminal operators." Reproductive Toxicology 4, 1990, pp. 61-65. Schnorr, T.M. et al. "Video display terminals and the risk of spontaneous abortion." New England Journal of Medicine 324, 1991, pp. 727-33. Sheehan, Mark. "Avoiding carpal tunnel syndrome: A guide for computer keyboard users." University Computing Times, University Computing Services, Indiana University-Bloomington, July-August 1990, pp. 17-19. Sheehan, Mark. "VDT Health risks: What to do while the jury's out." University Computing Times, University Computing Services, Indiana University-Bloomington, July-August 1990, pp. 16-17. Somers, William, et al. "Computers and health--A checklist" University Computing Times, University Computing Services, Indiana University- Bloomington, May-June 1991, pp. 4-5 The San Francisco Worker Safety Ordinance, January 1991 (sidebar) =================================================================== Amending Part II, Chapter 5 (health code) of the San Francisco Municipal Code by adding Article 23 requiring employers who employ video display terminal (VDT) operators to comply with worker safety requirements. Findings. Cites consensus of NIOSH, World Health Organization (WHO), and American National Standards Institute (ANSI) that adjustable VDT workstations in combination with training on proper adjustment and periodic breaks lead to safer and healthier work environment for VDT operators. Definitions. Employer defined as having 15 or more employees in city, including city government but excluding state and federal government. Operator defined as employee who may be expected to use VDT 4 hours or more per shift. Workstation standards. All operators to be provided with user-adjustable workstations, and chairs that are upholstered, swiveling, with seat pan and backrest adjustable for height and angle. Arm rests, padded wrist rests, and foot rests to be provided upon operator request; wrist rests shall enable operator to maintain neutral wrist position. Terminal display support adjustable so the entire primary viewing area of the terminal is between zero and sixty degrees below the eyes. Keyboard, detachable from terminal, in combination with seating and work surface, adjustable so forearms, wrists, and hands can be parallel to the floor. Document holder, adjustable for height and angle, provided upon request. Screens free of perceptible flicker. Direct noise of impact printers reduced by covers or isolation. Illumination. Level between 200-500 lux; task lighting upon request. Glare to be eliminated by shielding windows, positioning terminals at right angle to window, and/or anti-glare screens. Alternative work. Breaks (non-VDT work, rest break, or meal break) to be provided for 15 minutes after every 2 hours of repetitive keyboard work. Additional research. Advisory Committee to provide within two years: (1) recommendations for protecting operators from possible VDT radiation, including such methods as maintaining a distance of 1 meter from side or rear of any terminal; and (2) recommendations for minimizing adverse pregnancy outcomes and long-term visual impairment. In the interim, employer encouraged to provide pregnant operators with transfer on request. Employee education and training. Within six months, information to be provided on known and suspected health effects found to be associated with VDT work, known and suspected causes of health effects, protective measures that may be taken including workstation adjustments and visual examinations, eye and body exercises, and rights under the ordinance. Employee Rights. No discharge or discrimination against complainants. Timetable. Within 1 year, all new work station furniture must be in compliance; within 30 months, upgrade as necessary, but not in excess of $250/station; within 4 years, full compliance by replacement or upgrading. Miscellany. Right to entry and inspection. Penalties up to $500/day. Carpal Tunnel Syndrome (sidebar) ================================ Carpal Tunnel Syndrome (CTS) is a painful, debilitating condition involving the median nerve and the flexor tendons that extend from the forearm into the hand through a "tunnel" made up of the wrist bones, or carpals, and the transverse carpal ligament. As the hand and fingers move, the flexor tendons rub against the sides of the tunnel. This rubbing can cause irritation of the tendons, causing them to swell, which in turn, applies pressure to the median nerve. The result can be tingling, numbness, and eventually severe pain. CTS can be treated with steroids, anti-inflammatories, physical therapy, or, in advanced cases, surgery. CTS has many causes, including genetic predisposition, health and lifestyle, trauma, and repetitive motion--especially if the motion is in an awkward position, under stress, or insufficient recovery time is allowed in the work routine. Early symptoms include a tingling in the fingers, often beginning several hours after work activity has stopped. At the first sign of CTS, you should be examined by a doctor who specializes in hand and wrist disorders. If detected early, much of the pain, all of the disability, and surgery costs often exceeding $20,000 can be avoided. Authors:
Daniel Updegrove, currently University Director, Information Technology Services, Yale University; at time of publication, Associate Vice Provost, Information Systems and Computing, University of Pennsylvania. Kimberly Updegrove, formerly Lecturer in the University of Pennsylvania School of Nursing's Graduate Program in Nurse-Midwifery, is currently a practicing Nurse Midwife in New Haven, Ct.