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PubMed2005

Asbestosis in an asbestos composite mill at Mumbai: a prevalence study.

BACKGROUND: Of an estimated 100,000 workers exposed to asbestos in India, less than 30 have been compensated. The reasons for such a small number are: refusal by management sponsored studies to grant medical certifications to workers suffering from occupational diseases, lack of training for doctors in diagnosis of occupational lung diseases, deliberate misdiagnosis by doctors of asbestosis as either chronic bronchitis or tuberculosis and the inherent class bias of middle class doctors against workers. The aim of the study was to identify workers suffering from Asbestosis (parenchymal and pleural non-malignant disease) among the permanent workers of the Hindustan Composites Factory and assess their disability and medically certify them, whereupon they could avail of their basic rights to obtain compensation and proper treatment. METHODS: The study was conducted by the Occupational Health and Safety Centre and the Workers' Union. Asbestosis was diagnosed if they had an occupational history of asbestos exposure for at least 15 years and showed typical radiographic findings. RESULTS: Of 232 workers in the factory, 181 participated in the survey. 22% of them had asbestosis. All the asbestos affected workers had at least 20 years of exposure. 7% had rhonchi, 34% had late basal inspiratory rates, 82% had more than 80% of Forced Expiratory Volume in the first second (FEV1)/Forced Vital capacity (FVC) ratio and 66% had FVC less than 80% of the predicted value. On radiology 7% had only pleural disease, 10% had both pleural and parenchymal disease and 82% had only parenchymal disease. The association of pleural disease with chest pain was statistically significant. CONCLUSION: We found the prevalence of asbestosis among exposed workers to be less than that anticipated for the number of years of exposure due to "Healthy Worker Effect". We suggest that all affected asbestos workers (including those who have been forced to leave) in India be medically certified and compensated. We also recommend better control of asbestos use in India. We also implore the management to provide all information about the work process and its hazards, conduct medical checkups as mandated by law and give the medical records to the workers.

Adult↗
PubMed2000

Mortality among Catholic nuns certified as radiologic technologists.

BACKGROUND: Several studies have shown that Catholic nuns have a different mortality experience than women of similar age in the general population. We had a unique opportunity to evaluate mortality patterns of nuns identified in an occupational study of nearly 145,000 radiologic technologists (73% female). METHODS: A total of 1,103 women were classified as nuns based on their titles of "Sister" or "SR". Their mortality experience was compared to other female radiologic technologists and to U.S. white females. RESULTS: Five hundred eighty-three nuns (53%) were deceased as of January 1, 1995. Compared to other technologists, nuns were at significantly increased risk of dying from all causes (Standardized mortality ratio (SMR)=1.1; 95% Confidence interval (CI)=1.0-1.2, stomach cancer (SMR=2.7; 95% CI=1.2-5.4), diabetes (SMR=2.2; 95% CI=1.0-4.1), ischemic heart disease (SMR=1.2; 95% CI=1.1-1.4), all digestive diseases (SMR=2.0; 95% CI=1.3-3.0), and gastric and duodenal ulcers (SMR=8.3; 95% CI=2.3-21.3). In contrast, we observed a significant deficit in lung cancer (SMR=0.5; 95% CI=0.2-0.9), no deaths from cervical cancer, and a breast cancer risk 10% lower than expected (SMR=0.9; 95% CI=0.6-1.3). When compared to U.S. females, nuns experienced significantly reduced mortality from all causes (SMR=0.8; 95% CI=0.7-0.9), cervical cancer (SMR=0.0; 95% CI=0.0-0.7), all endocrine, metabolic and nutritional diseases (SMR=0.5; 95% CI=0.3-0.9), all circulatory diseases (SMR=0.7; 95% CI=0.7-0.8) including ischemic heart disease and cerebrovascular disease, and all respiratory diseases (SMR=0.5; 95% CI=0.3-0.8), and a nearly significant deficit of diabetes (SMR=0.6; 95% CI=0.3-1.0). In contrast, nuns had an almost 3-fold greater risk of tuberculosis (SMR=2.9; 95% CI=1.4-5.3) and a 20% excess of breast cancer (SMR=1. 2; 95% CI=0.8-1.7). The breast cancer excess was concentrated among nuns first certified before 1940 (SMR=2.0; CI=1.3-3.0), when radiation doses were possibly the highest, but the risk did not increase with increasing length of certification. CONCLUSIONS: Compared with the general population, the mortality experience of nuns was favorable and reflected the "healthy worker effect" commonly seen in occupational studies. Patterns observed for breast and cervical cancer possibly indicate differences in reproductive and sexual activities associated with belonging to a religious order. The possibility of a radiation-related excess for breast cancer among nuns certified before 1940 cannot be completely discounted, although there was no dose-response relationship with a surrogate measure of exposure (number of years certified). When their mortality experience was compared with other radiologic technologists, the influence of lifestyle factors was not apparent. Am. J. Ind. Med. 37:339-348, 2000. Published 2000 Wiley-Liss, Inc. dagger

Adult↗
PubMed1999

British Airways flightdeck mortality study, 1950-1992.

OBJECTIVE: To study the mortality and life expectancy of male British Airways flightdeck crew and to establish whether proportionate mortality excesses shown earlier for brain/CNS cancer, colon cancer and melanoma remained evident. METHODS: A Standardized Mortality Ratio study (SMR) using England and Wales as the comparison population was carried out for 6209 male pilots and 1153 male flight engineers employed for at least 1 yr between January 1, 1950 and December 31, 1992. Internal relative risk comparisons were made between shorthaul and longhaul operations defined broadly as flights within Europe and beyond Europe, respectively. RESULTS: The all-causes SMR for pilots of 61 (592 deaths) and 56 for flight engineers (127 deaths) confirmed the expected Healthy Worker Effect. In pilots apart from the known excess of deaths from aircraft accidents (SMR 14694), most of the comparisons showed significant deficits in mortality. The SMR's for brain/CNS cancer (143) and colon cancer (111) were no longer statistically significant. The SMR of 333 for melanoma was significantly raised in pilots but was not evident in flight engineers. Life expectancy for longhaul pilots and flight engineers was 4-5 yr better than England and Wales for ages 55-65 while the advantage for shorthaul pilots was reduced to between 2-3 yr. Cases of leukemia and aleukaemia in pilots were less than expected and less than the positive excess predicted from modeling based on radiation dose. CONCLUSION: The study confirms that flightdeck crew live longer than the England and Wales population and do not exhibit patterns of death that could be directly attributable to occupation.

Accidents, Aviation↗
PubMed2005

Mortality of workers exposed to ionizing radiation at the French National Electricity Company.

BACKGROUND: Exposure to ionizing radiation increases the risk of cancer in humans. Nuclear workers receive low doses over a relatively long period of time. METHODS: A mortality study of a cohort of workers exposed to ionizing radiation at Electricité de France (EDF) was conducted. The cohort consisted of 22,395 individuals monitored for radiation exposure between 1961 and 1994, and followed-up for an average of 11.7 years. RESULTS: Our study demonstrates a clear healthy worker effect (HWE) since mortality is less than half what is expected from National mortality statistics. The HWE is greater among workers who have spent most of their career in the nuclear sector. The analysis by cancer site shows no excess compared with the general population. No significant trend was observed according to level of exposure to ionizing radiation. CONCLUSIONS: The mortality of workers exposed to ionizing radiation at the French National Electricity company is very low compared to the French national mortality.

Adolescent↗
PubMedDate not supplied

A retrospective cohort study of cancer incidence among New York State Farm Bureau members.

Cancer incidence from 1973 through 1983 in 18,811 New York Farm Bureau members was examined using a retrospective cohort study design. The observed number of cancers for all age groups was 72% of the expected, and the major deficits in incidence occurred for lung (52% of expected), gastrointestinal (67% of expected), and bladder (78% of expected). Similar deficits have been reported by other researchers. Unlike other studies, we did not find a significant excess of cancer of any site. Given the healthy worker effect and the small numbers of incident tumors at some sites, the Standardized Cancer Incidence Ratios that were over 100 in value (i.e., lip, melanoma of the skin, prostate, multiple myeloma) merit further investigation. This study differs from previous research in population, setting, and method. Nonetheless, the general pattern of results is consistent with the findings of other investigations.

Adolescent↗
PubMed2006

Do ambient noise exposure levels predict hearing loss in a modern industrial cohort?

BACKGROUND: Much of what is known about the exposure-response relationship between occupational noise exposures and hearing loss comes from cross-sectional studies conducted before the widespread implementation of workplace hearing conservation programmes. Little is known about the current relationship of ambient noise exposure measurements to hearing loss risk. AIM: To examine the relationship between rates of high frequency hearing loss and measured levels of noise exposure in a modern industrial workforce. METHODS: Ten-year hearing loss rates were determined for 6217 employees of an aluminium manufacturing company. Industrial hygiene and human resources records allowed for reconstruction of individual noise exposures. Hearing loss rates were compared to ANSI 3.44 predictions based on age and noise exposure. Associations between hearing loss, noise exposure, and covariate risk factors were assessed using multivariate regression. RESULTS: Workers in higher ambient noise jobs tended to experience less high frequency hearing loss than co-workers exposed at lower noise levels. This trend was also seen in stratified analyses of white males and non-hunters. At higher noise exposure levels, the magnitude of hearing loss was less than predicted by ANSI 3.44 formulae. There was no indication that a healthy worker effect could explain these findings. The majority of 10 dB standard threshold shifts (STS) occurred in workers whose calculated ambient noise exposures were less than or equal to 85 dBA. CONCLUSIONS: In this modern industrial cohort, hearing conservation efforts appear to be reducing hearing loss rates, especially at higher ambient noise levels. This could be related to differential use of hearing protection. The greatest burden of preventable occupational hearing loss was found in workers whose noise exposure averaged 85 dBA or less. To further reduce rates of occupational hearing loss, hearing conservation programmes may require innovative approaches targeting workers with noise exposures close to 85 dBA.

Adult↗
PubMed2005

Mortality of iron and steel workers in Korea.

BACKGROUND: The mortality experience of iron and steel workers from modern plants in developing countries has not been extensively described. METHODS: Mortality at two Korean iron and steel manufacturing complexes was analyzed using Poisson regression methods with both direct and indirect standardization. Work histories were linked with a national mortality registry. Workers (44,974) hired beginning in 1968 were followed from 1992 to 2001. RESULTS: The 806 deaths observed during 10 years of follow-up comprised 2% of the population at risk and represented a large healthy worker effect (HWE) for all causes (SMR = 0.59, 95% CI = 0.55-0.63) and for cancer (SMR = 0.79, 95% CI = 0.70-0.90). Mortality at subsidiaries was considerably higher than at the parent plants (SRR = 1.71, 95% CI = 1.47-1.99). Relative mortality rates declined with employment duration: > 20 years had significantly reduced mortality (SRR = 0.59, 95% CI = 0.43-0.82) compared to duration < 1 year (test for trend: P = 0.0006). Fatal injury deaths in the first year were highly elevated (SMR = 3.10, 95% CI = 2.17-4.26) declining to less than that expected after 5 years. Cancer mortality was elevated in stainless steel production (SRR = 3.26, 95% CI = 1.37-6.49) and overall mortality was elevated for work in plant maintenance departments (SRR = 1.17, 95% CI = 1.00-1.37), particularly for fatal injuries (SRR = 1.67, 95% CI = 1.29-2.14). All-cause mortality increased with employment duration in the steel-production departments, as did fatal injuries in material handling/construction. CONCLUSIONS: This steelworker cohort exhibits excess mortality in some process areas. More detailed retrospective exposure assessment and future follow-up of this cohort will better define health risks in the modern iron and steel manufacturing.

Cardiovascular Diseases↗
PubMed1999

Cancer mortality among radiological technologists in Japan: updated analysis of follow-up data from 1969 to 1993.

A retrospective cohort study was conducted for 12,195 male radiological technologists who received the occupational exposure to low dose radiation over a long term. A total of 1,097 deaths including 435 from cancer were ascertained by Koseki and death certificates from 1969 to 1993. Cancer mortality among the study population was basically compared with that of whole Japanese men. The significant low SMRs were obtained for all cancers, stomach and lung cancer partly due to Healthy Worker Effect, unlike the results of the early reports with some inappropriateness in the methods. Apparent high risks of lymphatic and hematopoietic cancers were observed, although none of site-specific cancers revealed the statistically significant increase. For these cancers, the SMRs among old sub-cohort were somewhat higher than those of young sub-cohort, whereas similar SMRs for solid cancer were obtained between the two sub-cohorts. The SMR for leukemia reached statistically significant level of 1.75 (95% CI: 1.07-2.71) when using whole professional and technical workers as a standard population. The study results might suggest that the chronic exposure to low-dose radiation enhanced the risk of lymphatic and hematopoietic cancers.

Adult↗
PubMed2006

Cancer morbidity in iron and steel workers in Korea.

BACKGROUND: In the iron and steel industry, workers are potentially exposed to a number of carcinogens and are involved in a number of processes of a hazardous nature. The cancer morbidity of iron and steel workers from modern plants in a developing country is described. METHODS: Cancer morbidity at two Korean iron and steel complexes was analyzed using Poisson regression methods. Work histories were merged with the national cancer registry for 44,974 workers who were followed from 1988-2001. RESULTS: Four hundred sixty-four cancers, in 1% of the population, were diagnosed over 14 years. Based on national cancer rates, the cohort exhibited a healthy worker effect for all cancer (SIR = 0.87, 95% CI = 0.79-0.95) reflecting relative good health, particularly for lung cancer (SIR = 0.58, 95% CI = 0. 04-0.82), stomach cancer (SIR = 0.78, 95% CI = 0.64-0.93), and liver cancer (SIR = 0.83, 95% CI = 0.68-1.01). Lung cancer morbidity was significantly elevated at the affiliated plants versus the parent plants (SRR = 2.35, 95% CI = 1.07-4.92), and all-cancer morbidity was significantly elevated for maintenance workers compared to office and production workers (SRR = 1.27, 95% CI = 1.00-1.60). Lymphohematopoietic cancer incidence was higher in the coke plants (SRR = 3.46, 95% CI = 1.02-8.91) and stomach cancer incidence was higher in the maintenance departments (SRR = 1.66, 95% CI = 1.05-2.56). CONCLUSIONS: This recent steelworker cohort exhibits possible excess cancer morbidity in some processing areas. Further follow-up of this cohort and alternate study designs such as case-control study will be needed to elucidate the relationship of exposure and health risks of iron and steel workers.

Healthy Worker Effect↗
PubMed1992

Mortality among female manual workers.

STUDY OBJECTIVE: The aim was to determine whether female manual workers have higher mortality than other women. DESIGN: This was a retrospective cohort study in which mortality was compared with that of the general female population. Main outcome measures were standardised mortality ratio (SMR) and 95% confidence intervals (CI). SETTING: Reykjavík region. PARTICIPANTS: Participants were 18,878 women, the cumulated members of a pension fund for manual workers between 1970 and 1986. MAIN RESULTS: A healthy worker effect was observed in the total cohort. The study was then restricted to those who had contributed to the pension fund any time after reaching 20 years of age, and a 10 year latency period was instituted. When analysing subcohorts by duration of employment the standardised mortality ratios for all causes of death and all cancers increased with longer employment time up to 10 years. However, the ratios were low in the group with over 10 years of employment. Those who began contributing to the fund in 1977 or later had higher mortality than those who began earlier. There was an excess of lung and bladder cancer in the total cohort and in all the subcohorts except in the group with over 10 years' employment. Mortality from accidents and suicides was in excess in all the groups. CONCLUSIONS: Mortality is high among some groups of female manual workers. A deficit was found among those with the longest employment. Differences in mortality have widened in recent years. An excess of suicides shows that women in this group have, for some reason, less will to live than other women.

Adult↗
PubMedDate not supplied

Longitudinal study of workers in an aluminum smelter.

We conducted a 6-y follow-up study that included workers in an aluminum smelter in British Columbia. Of the original cohort, 951 workers left the industry and 985 workers participated in both studies. Comparison of those who left and those who remained showed that those who left were (1) older, (2) had a slightly higher prevalence of respiratory symptoms, and (3) had lower lung function; this was especially true for workers who were 50 + y of age at the time the initial study was conducted. Analyses were conducted only on 586 male workers who did not change their job location or smoking habits between the initial and the follow-up study. Potroom workers in the "high-exposure" group had a significant reduction in the prevalence of cough, but experienced an increase in the prevalence of wheeze. There was no significant difference in the annual decline in forced expiratory volume in 1 sec and forced vital capacity between the potroom workers and controls. In general, older workers and smokers had a greater decline in lung function compared to younger workers and nonsmokers. Leukocyte count done during the initial study was found to be an independent predictor of longitudinal decline in lung function. The lack of exposure effect on longitudinal decline in lung function could be due to "healthy worker" effect and improvement in the working condition of the smelter.

Adult↗
PubMed2004

Atopic and non-atopic asthma in a farming and a general population.

BACKGROUND: In a previous study inverse associations between asthma and exposure to fungal spores and endotoxins in atopic farmers and positive associations with the same factors in non-atopic farmers were documented. No external reference population had been included. We, therefore, compared this farming population with the general population from an adjacent region. METHODS: Random samples of a farming (n=2,106) and a rural (n=351) and urban (n=727) general population were selected. Atopy was assessed by serum IgE and asthma by questionnaires. RESULTS: The asthma prevalence was 4.0% among farmers, 5.7% in the rural, and 7.6% in the urban population. Atopy was similar (9-10%). Most asthmatics were not atopic, 67-75%. Farmers had asthma less often than the general population OR 0.52 (95% CI 0.36-0.75); both atopic (OR 0.33 (95% CI 0.15-0.69)) and non-atopic asthma (OR 0.60 (95% CI 0.39-0.93)). CONCLUSION: This may indicate a protective effect of the farm environment on asthma but a healthy worker effect may also play a role.

Adult↗
PubMed2002

Respiratory symptoms and diseases among workers in the soft tissue producing industry.

AIMS: To correlate the prevalence of respiratory tract symptoms and diseases with dust and fibre exposure in the soft tissue industry in Germany. METHODS: Ambient monitoring was performed for inhalable, respirable dust and fibres in seven soft tissue producing factories. In 441 workers (72 controls, 90 moderate, 279 high exposure) a standardised questionnaire on respiratory symptoms, diseases, occupational history, and smoking habits was used. Crude differences in the prevalence of respiratory symptoms and diseases were assessed. Logistic regression analysis was used to determine the relation between the respiratory symptoms/diseases and the cumulative dust and fibre exposure, respectively, while adjusting for age, gender, smoking habits, and factory. The effects of exposure intensity and duration were differentiated by categorising dust/fibre concentrations and years of exposure separately and setting up logistic regression models. RESULTS: The mean concentrations for inhalable, respirable, and fibrous dusts were 10.3 mg/m(3), 0.22 mg/m(3), and 415,000 fibres/m(3). Adjusted odds ratios (OR) with relation to cumulative dust exposure intensity were significantly raised for blocked nose (18.2), mucosal irritation (6.5), dry nose (8.9), cough (3.5), phlegm (7.5), exercise induced dyspnoea (2.6), hoarseness (11.3), and sneezing attacks (7.9) (ORs for highest exposure categories). Cumulative dust or fibre exposure had no significant effects on the prevalence of respiratory diseases. For all symptoms with significantly raised ORs, combined effects of intensity and duration of exposure were found. CONCLUSIONS: Because of the high prevalence of respiratory symptoms a reduction of dust exposures is recommended. Chronic exposure effects could not be found in this study, however, a healthy worker effect has to be considered.

Adult↗
PubMed1984

Pulmonary function and respiratory symptoms in potash workers.

Over 94% of the workers in each of four Saskatchewan potash mines participated in a respiratory health surveillance program that included a questionnaire and pulmonary function tests. Compared with a nonexposed control group, potash workers had higher prevalences of cough, dyspnea, and chronic bronchitis but better pulmonary function. Prevalences of symptoms and pulmonary function abnormalities were similar among workers at the four mines tested and at the various job locations. Potash dust, diesel fumes, and other air contaminants may have an irritant effect that leads to the increased prevalences of cough and chronic bronchitis. Although we found no adverse effects of the potash mine environment on pulmonary function, these findings reflect a healthy worker effect or some selection process that makes the potash workers appear healthier in a cross-sectional study.

Adult↗
PubMed1984

Respiratory effects of two types of solder flux used in the electronics industry.

Fumes from solder flux have been shown to cause asthma among solderers in a British electronics factory. In the present study, questionnaires and lung spirometry were administered to 104 U.S. electronics workers (93 women, 11 men) who soldered printed circuit boards. Two types of solder flux were used: 68 subjects had worked only with a rosin-core (colophony) solder; 36 had changed from rosin- to an aqua-core ("phosphorous hexate") solder 15 months before the study. Symptoms of eye, throat, and nose irritation occurred in nearly half of the total group. Lower respiratory tract symptoms, including cough, phlegm production, and wheezing, also occurred with increased frequency, compared with reported rates among a general population. Similar symptom rates were observed among the aqua- and rosin-core groups. That these symptoms were work related was indicated by the subject's improvement on weekends or during vacation periods. On average, lung spirometry performed before starting work on Monday mornings showed no impairment in lung function; over the course of the work day there were small decrements in the forced expiratory volume at 1 s (mean, -21 +/- 11 [SD] ml) and forced vital capacity (-30 +/- 145 ml), but these decrements were unrelated to the individual amounts of solder used during the same period. Among the white female workers (N = 83), several multivariate analyses indicated that an increase in the amount of soldering had a beneficial effect on lung function, particularly among those who currently smoked. This paradox probably resulted from a "healthy worker effect" resulting from some individuals with lower than average lung function who left the industry early in the course of their employment.

Adult↗
PubMed1995

Women's employment, marriage, motherhood and mortality: a test of the multiple role and role accumulation hypotheses.

Two contrasting hypotheses on the effects of combining marital, parental and work roles on mortality are analysed in this paper. The 'multiple role' hypothesis suggests that the effects are harmful, but the 'role accumulation' hypothesis argues that the benefits will outweigh the possible harmful effects. This paper uses record linkage data for all 35-64 year-old non-pensioned Finnish women to examine the two hypotheses. Women with all three roles of wife, mother and employee had low mortality. This, however, was a reflection of the main effects of these three variables. Only lone mothers with > 1 child--about 4% of the study population--were characterized as having a somewhat deviant mortality from what was to be expected on the basis of the main effects model. The high mortality in this group was mainly due to causes of death related to accidents and violence and circulatory diseases. Further analysis indicated that the excess mortality among lone mothers with two or more children and the lack of interactions for any other role constellation was similar in all age and educational groups. It is concluded that neither of the hypotheses on multiple roles are very relevant for the analysis of female mortality and that more attention should be devoted to understanding the contribution of possible selection effects leading to marriage and motherhood and the contribution of the 'healthy worker effect' in creating low mortality for the employed.

Adult↗
PubMed1984

Women and work: an investigation of the association between health and employment status in middle-aged women.

Considerable controversy has appeared in recent epidemiological literature on the association between unemployment and health. Other recent research suggests that there is an association between women's employment status and their physical and mental health. Although the nature of this association has still to be specified, it is of increasing importance given the dramatic rise in work force participation in the last few decades. This paper analyzes the results of the first large U.S. epidemiological study of the menopause in over two decades, comprising a random sample (n = 8114, response rate = 77%) from the general population of women aged 45-54 in Massachusetts. Women who were employed for pay (69%), full time homemakers (24%) and women who were unemployed themselves (5%) or living with an unemployed spouse (2%) were included in this analysis of data from the cross-sectional phase of the study. Comparisons between a variety of measures and employment status are reported, as are the intervening effects of sociodemographic variables and social support measures. The importance of the 'healthy worker effect', especially for homemakers, is analyzed. Finally, a small subsample of recently unemployed women from the first round of the longitudinal phase of the study is analyzed to demonstrate additional information to be gained through a longitudinal design.

Cross-Sectional Studies↗
PubMed1998

Low overall mortality of Turkish residents in Germany persists and extends into a second generation: merely a healthy migrant effect?

OBJECTIVE: To test the hypothesis that as a minority with lower socio-economic status, Turkish residents in Germany might experience a higher mortality than Germans. METHODS: All-cause mortality rates by age group and sex of Turkish and German adults for the time period 1980-94 were calculated from death registry data and mid-year population estimates. RESULTS: The age-adjusted mortality rate (per 100000) of Turkish males aged 25-65 years resident in Germany was 299 in 1980 and 247 in 1990, consistently half that of German males. The mortality of Turkish females in Germany was 140 in 1990, half that of German females. Mortality of Turkish males/females in Ankara was 835 and 426 in 1990. CONCLUSION: In view of the socio-economic status of Turkish residents in Germany the large mortality difference compared to Germans is unexpected. It cannot be fully explained by a selection at the time of hiring (healthy migrant effect) because it lasts over decades and extends into the second generation. A healthy worker effect is unlikely because Turkish residents have a lower employment rate than Germans. There is little evidence for movement of gravely ill persons back to Turkey. An 'unhealthy re-migration effect' in which socially successful migrants with a lower mortality risk stay in the host country while less successful ones return home even before becoming manifestly ill would partly explain our findings.

Adult↗