The logic is simple. Chronic ailments like heart disease, diabetes and mental health conditions such as depression and anxiety are on the rise. Each of these lists stress as a major causal factor. What’s the No.1 source of stress, according to multiple studies? Work.
Here are some numbers: the World Health Organization (WHO) reported a tenfold increase in the incidence of diabetes, from 1.2% of Indians in 1971 to 12.1% in 2000. A study led by Rajeev Gupta and published in May by Elsevier, an information analytics company, reports that deaths due to heart disease have gone up by 34% over the last 25 years. According to a study released in September and conducted by the Indian Council of Medical Research, the Public Health Foundation of India and the Institute for Health Metrics and Evaluation, in India, suicide is the leading cause of death in the 15-39-year-old age group.
When it comes to stress, we are a bit like the six blind men: while we know how it affects our brains, heart and the digestive system, we fail to put together a picture of the whole elephant. And the elephant is in the room: in our living rooms, in our hospitals, and in our offices. The stories come from every sector of the economy.
R, a graduate from a top B-school, landed a plum job in finance three years ago. He expertly broke down his workweek: “I spent 13 hours at work from Monday to Friday. After taking out time needed to commute, I got 30 minutes with my spouse in the morning, while getting ready, and 30 minutes to relax before sleeping. Saturdays, I worked an additional 6-7 hours."
This punishing schedule immediately compromised his mental health. “Even after 13 hours, I’d have no feeling of accomplishment. My mind would race thinking of tomorrow’s workload. On some days, I could only think of curling up and crying, wondering what the f*** was going on in my life."
To cope, R turned to stimulants, consuming four cups of coffee, three cups of tea, and six cigarettes a day. The job came with perks: taxi rides home and dinners on the house. Since the work was so arduous, R felt compelled to indulge. “Because dinner was the only good part of the day, I went all out, treating myself to unhealthy foods." At the age of 31, he has elevated levels of blood cholesterol.
A 2018 Optum Health Risk Assessment survey with 800,000 respondents from over 70 Indian employers found that over half of professionals suffer from high stress. The 2016 edition reported that 43% had a skewed body mass index (BMI), and 30% were at risk of diabetes and hypertension.
Stress comes calling early
Stress starts early in India. Every hour, a student commits suicide here, according to 2016 data sent to the ministry of home affairs by all states and Union territories. Stress escalates when they enter the workforce: in a 2016 ManpowerGroup survey of 19,000 millennials in 25 countries, Indian millennials reported working the longest hours, 52 hours a week. A 2018 Cigna-TTK survey had a whopping 95% of Indian millennials reporting high levels of stress. All this is leading to heart disease. Data from the Indian Heart Association shows that 25% of heart attacks in Indian men hit those younger than 40.
Ironically, doctors are the hardest hit. Neeraj Kumar Tulara, a senior consultant physician at the Dr L H Hiranandani Hospital in Mumbai, says, “A study we conducted among doctors found that the older, first generation had a much higher life expectancy than the younger, third generation. Our study showed little change in diet and other factors, leaving stress as the most likely cause for premature death among doctors," says Tulara.
Premature death has increased across professions. “Lifestyle factors like poor diet and smoking take time to affect health," Tulara continues. “The only explanation for sudden death in young people is stress."
In hospitals, it is the medical resident who faces the most exploitation. V, now a senior resident at a Mumbai hospital, says, “Despite living only 30 minutes away from my family during my three-year residency, I did not go home once." Work was so intense that V would have her first meal at 5pm. “We would be so hypoglycemic that we would feel faint. All residents ate from small packets of sugar in their pockets to prevent collapsing." V carries those packets to this day.
As part of her training, V spent some weekends “on call", which means being available throughout the day. She would enter the hospital on Friday afternoon, and exit on Monday afternoon. Facilities provided to resident doctors are often woefully inadequate. “We were given one patient room—two beds—that we shared among 14 residents," V says. “Even then we were told we were denting the hospital’s revenue."
When doctors at V’s hospital requested a bigger team, the management refused, quoting 50% capacity utilization of operation theatres (OTs). But a hospital is not a hotel. “There were several nights when I was juggling two major surgeries at the same time. On one night, just one consultant and me, a junior resident, had to oversee four simultaneous surgeries."
Things got worse when V was diagnosed with multi-drug resistant tuberculosis. What leads to TB? Poor eating habits, stress, and lack of sleep and fresh air. According to V, and corroborated by insider estimates, one in three residents develop TB due to terrible work lives and exposure to tuberculosis patients. Instead of getting medical leave, residents at V’s hospital were told, “Don’t overreact, it’s all a part of learning." Some even bullied V, saying, “No one will marry a TB patient." Bullying worsens work stress, and the cocktail is lethal. V says, “Just last year, three students from one batch of postgraduate residents in Mumbai committed suicide citing stress and work conditions."
I asked about bullying on my IIM batch’s WhatsApp group. “Everyone will have a story like this," one member said. Another member, who works in an FMCG MNC, said she constantly hears statements like, “Which idiot gave you this job?" and “You don’t deserve the salary you get." “These aren’t even considered nasty," she says. “Nice people use these." Corporate India seems to be one place where people sledge their own teammates.
Accept there is a crisis
What can we do about it? First, acknowledge the problem.
Stanford professor Jeffrey Pfeffer estimates there are 120,000 extra deaths each year directly resulting from harmful management practices in the US, and puts the extra healthcare costs at $190 billion (around ₹ 14 trillion). Workplaces were the fifth-leading cause of death. He hopes this evidence, collected in his book Dying For A Paycheck (published in March), will overwhelm our denial of this crisis.
Though these are US numbers, they emphatically apply here too. India stands to lose $4.58 trillion due to stress-related chronic diseases before 2030, as reported by a 2014 World Economic Forum (WEF)/Harvard School of Public Health study. Asked about the Indian context, Prof. Pfeffer says over email, “The health and other consequences are almost certainly the same across cultures, as the etiology of the stress-induced diseases and the psychological impact of work is likely to be identical."
Second, stop fixing the individual: fix the environment.
Corporations are becoming aware of the crisis. The WEF/Harvard study mentions that 42% of Indian business leaders have serious concerns about the impact of chronic illnesses on revenue, profitability and productivity, and a 2018 international “Wellness in the Workplace" Optum survey reports that 76% of firms expect spending on wellness programmes to go up in the next three years. Unfortunately, these programmes fail to address toxic work environments. As a result, employees are unenthusiastic: engagement in wellness programmes hovers between 25-33%.
The truth is, work environments are more culpable than individual behaviours. As Bob Chapman, CEO of manufacturing technology and services supplier Barry-Wehmiller International, says, your line manager, and the stress they expose you to, can influence your health more than any treatment prescribed by your family doctor. And workplace factors can actually cause unhealthy behaviours. Prof. Pfeffer writes, “extensive research shows that individual health-related decisions such as drinking, smoking, drug abuse and overeating are profoundly affected by job-related conditions."
Individual efforts to fix habits without fixing the environment are doomed to fail. S, 30, is a copywriter working in the media and advertising field. A few years ago, he would spend 13 hours at work, eating every meal outside, and using intoxicants to cope. “We would go out for drinks and get back to work. We also turned a cubicle into a smoking room. We were smoking 30 cigarettes a day."
The physical impacts were immediate. “In four years, I put on 17kg," S says. He tried taking responsibility for his health. “There was a gym in the office, but I had to fight with my boss to use it (his boss had himself been hospitalized for high blood pressure, and would have his first heart attack at 40)." Initially, S’s efforts bore fruit. “Once I took a stand, a few of my colleagues joined me at the gym." But this lasted a month. Soon, work increased, making it impossible to take time out for gymming. S developed cervical degenerative disc disease at 28, which doctors said only occurs after people turn 40.
But the worst was still to come. S was hit by depression. “What would earlier take me 1 hour, now started taking 6. I couldn’t concentrate. I felt I was losing my ability to think."
Instead of recognizing that his work life had led to this, S continued to believe the problem lay in him. It was only after he changed jobs, working 8-hour days, that he began to get regular counselling.
Business leaders who can provide healthier workplaces will reduce attrition and poach top performers from competitors. But our toxic culture is so pervasive, leaders are wary of making a public commitment to do so. Two top executives I reached out to declined to be quoted about their efforts to change work culture. When an email by the Amazon India CEO, Amit Agarwal, asking top executives to reduce working after 6pm was widely reported about in the media in August, Amazon India declined to comment as well. Time, however, is running out. If things don’t get better, we can expect employees to intensify their search for exit strategies. A 2016 Timesjobs.com study found that 60% of employees in India plan to quit their jobs due to excessive stress. In September, The New York Times reported about the “Financial Independence, Retire Early (FIRE)" movement among millennials actively planning to leave the workforce by the age of 40.
Measure the impact
Third, measure the problem.
In our data-driven world, what isn’t measured doesn’t improve. Prof. Pfeffer recommends measuring the impact of toxic management practices, tracking rising medical costs, costs to productivity, and employee turnover as measures of unhealthy workplaces.
Then there are costs to society. Just as businesses externalized costs to the environment until governments stepped in with regulations, the same is occurring with the costs of toxic workplaces. If a person drops out of the workforce due to stress-related illness, the corporation can replace them; it is the patient who has to face high medical bills and job insecurity.
IESE Business School professor Nuria Chinchilla calls this “social pollution". Our work culture is leading to failing marriages, poor parenting relationships and loneliness. These costs do not accrue to the company; they are borne by society. Social pollution, just like environmental pollution, needs to be regulated.
Fourth, apply win-win solutions today.
Recent experiments show that alternatives exist. In July, Perpetual Guardian, a New Zealand company that manages trusts and estates, trialled a four-day workweek without reducing pay, and found gains in not just job satisfaction but also collaboration, efficiency and productivity. Stephan Aarstol, founder and CEO of Tower Paddle Boards, a beach lifestyle company, and author of The Five-Hour Workday, switched his company from a full day to an 8am-1pm schedule. Leave alone his company taking a hit, his revenue increased by 40%. His book inspired Lasse Rheingans of Rheingans Digital Enabler, a digital agency, to trial a 5-hour workday starting December 2017. All three firms have chosen to make the change permanent.
Some changes are basic: reducing bullying by supervisors, and making the office physical environment more comfortable. Prof. Pfeffer suggests two factors that can go even further.
The first of these is job control and autonomy. The famous Whitehall Studies, conducted by epidemiologist Michael Marmot among British bureaucrats, found that even after accounting for health factors and habits like smoking, the more autonomy a bureaucrat enjoyed, the lower was the risk of heart disease. Moreover, men at the lowest levels had six times the rate of absence because of sickness than men in the highest grade.
Forget work life, young employees don’t even control their personal lives. Both R and S mention this as key: “Work could come up at any time, making any sort of dinner plan impossible to make," says R. S adds, “Since I began working, I have had no control over even my weekends."
Shaving off hierarchical work relationships can help autonomy. BWDesign Group, an engineering and IT consultancy and the India office of Barry Wehmiller International, slashed job turnover from 25% to 11%, while growing the company and the leadership pipeline. It did so by offering the same health benefits across every layer of the organization, and creating “servant leaders"—bosses whose job it is to serve their employees by unleashing productivity and removing roadblocks. “We started a turnaround in a struggling India operation in 2015 by embracing themes of collaborative working and autonomy. The results were evident last year, when the India division made a significant profit," Lakshmi Priya Radhakrishnan, BWDesign’s director of culture and people development, says over email.
The second factor is social support. Prof. Pfeffer quotes a PLOS Medicine study from 2010 which says having close relationships protects “your health as much as quitting smoking and a great deal more than exercising." Cutting work hours can nurture family relationships, but work itself can become a vital social support. To begin, Prof. Pfeffer recommends nixing toxic practices like the grading-on-the-curve performance review. It has been shown to raise internal competition to levels where employees withhold information from colleagues, hurting the business. The “stack review system" was famously held responsible for Microsoft’s “lost decade" (marked by a steep decline in innovation and influence in the first decade of the millennium) in a piece published by Vanity Fair in 2012.
While it looks distant at the moment, we must not give up on imagining a future of work where it becomes a source of purpose and satisfaction, contributing to our health and well-being rather than detracting from it. Those of us who lead people are contributing to this culture. The transformation of work cannot be led by doctors or HR—line managers, starting from the very top, have to spearhead this effort, and, like true leaders, take responsibility for their people.