Operating a motor vehicle in the city is an activity not unfamiliar to most of us. Yet, the toll which this activity takes upon the human nervous system and target organs is, to say the least, under-appreciated in daily life. Try to imagine that rather than at most a couple of other known persons sitting in one's car during this undertaking, one were responsible for transporting thousands each day via narrow, hilly streets, facing innumerable obstacles and under inexorable pressure to keep to a strict schedule, and that the slightest accident could result in injury to a passenger and might even put one's job in question. And also imagine that rather than at most a few hours of this activity per day, this consumed eight or even more hours daily for five or more days in a row. These and many, many more stressors comprise the everyday experience of the San Francisco urban transport operators, who encounter problems specific to their city, but also in many ways, exemplify the difficulties which transit operators face in just about any metropolitan center which comes to mind.

On July 10, a group of us from the California Focused Study Group, had the opportunity of gaining a deeper insight into some of these difficulties and perils, during a "narrated" ride along San Francisco's Line 22. We were privileged to have a veteran transit operator talk us through the mental processes which were taking place while the actual driver proceeded to perform the job. This perspective was complemented by Dr. Birgit Greiner's observational methods to measure the barriers, obstacles, restrictive time binding and other stressors of urban transport operators.

Getting Started
An extremely important part of the transit operator's work is unseen by the public. This is the so-called "start-up" procedure. Before even beginning on the line, the operator must sign in, and meet a dispatcher to receive the schedule and find out about any detours, etc.. Under ideal circumstances, the dispatcher could be a source of support and encouragement. However, given the pressures of urban transport life faced by the dispatchers as well, this may prove to be quite the opposite, i.e. yet another stressor before even getting started. The operator then goes out into the yard to locate the assigned vehicle. A detailed safety check must be made on the vehicle, its destination sign set up, and the radio and fare boxes programmed. A working radio is the operator's "lifeline", i.e. the communication system without which he or she cannot proceed. The seat and mirrors must be adjusted. We observed that the right half of the driver's seat was totally worn out, due incessant pressure to turn to the right side. Equipment is often old and worn.

Ten minutes is allocated for the preparation within the yard. If any of these elements is not functioning properly, the allotted time becomes absolutely inadequate. Also, another coach may be blocking the way out, causing a delay. The first few minutes of operating the vehicle are the most precarious with regard to accident risk. It should be noted that this comes immediately after the checking procedure, which, as outlined, can be stressful in itself.

General Issues of Mass Transit Driving in Urban Areas
Drivers are responsible for the safety of their passengers and vehicle. Mass transit vehicles often handle poorly, brake slowly and, in the case of electric trolley cars, must be stopped only in locations where they will not lose contact with the overhead grid. Traffic is often heavy, pedestrians have the right of way and may demand it under dangerous circumstances (for themselves and the vehicle). There are often too many passengers and not enough buses. Drivers are frequently behind schedule and trying to catch up, and as a consequence may not be able to take the prescribed breaks. This may result in excessive fatigue, leading to frayed nerves, poorer driving and more conflict with passengers, etc. (a vicious cycle may ensue).

Specificity of San Francisco Mass Transit
One big problem for San Francisco is the hills. These affect visibility, and create difficulty in maneuvering. It requires substantial muscle strength to hold the brakes on the downhill; we could observe that the transit operator's right leg was held in full extension downhill.

San Francisco also has many narrow streets, not designed for the present situation of heavy traffic. A double-parked car on a narrow street can be sufficient to cause a major traffic blockage. Having to make sharp turns with a large vehicle on these streets is another challenge, slowing the driver down as well as being an accident-prone situation.

A number of the San Francisco mass transit lines are equipped with trolley buses; these are connected to the power line by a pole, which can be displaced. When this happens along a narrow street, traffic can become totally blocked. In the midst of the jam, the operator must get out of the vehicle, and try to put this connecting pole back in place using a tension cable. A number of us had the chance in the relative quiet of the yard to perform this maneuver, and can attest to the considerable physical strength needed to do so. When the driver tries to quickly put that pole back in place while standing in the midst of congested traffic, arm and shoulder injuries can easily occur.

Precisely because of the beauty of much the city and its panoramas, an ironic dichotomy may also be present for many of the San Francisco transit operators. That is, their visual attentional system must in fact shut this beauty out, in order to continuously monitor the traffic situation. But this dichotomy also suggests a very natural way for the drivers to recover at the end of the line: to step out of their vehicle and to have a chance to enjoy these lovely panoramas. Wouldn't that provide a fitting and immediate reward for successfully completely a driving tour. If accompanied by a brisk, invigorating walk, another health-promoting feature could be incorporated. The trade union demand for guaranteed rest breaks ("recovery time") is entirely coherent with what we know about healthy work practices. Drs. Kompier and Di Martino of the Netherlands and the International Labor Organization, recommend that city bus drivers have a minimum of twenty minutes' break after each two hours behind the wheel.

Yet, the transit operators often don't have a chance to take even the short break which is scheduled at the end of each driving tour. When the driver reaches the end of the tour behind schedule, there is seldom if ever any back-up available. Under these circumstances, knowing that passengers for the next tour are waiting, getting more impatient by the moment, most drivers opt to skip or at least shorten their break, in order to try to ameliorate that impatience, and to try to get back on schedule. What is really happening is that the driver sacrifices his or her own comfort, and in the long run, health and well-being, to compensate for the city's traffic congestion and the lack of adequate numbers of drivers and vehicles.

Furthermore, the bare minimal conditions for hygiene are frequently lacking at the rest site. The available restrooms, ill-maintained, are mainly found along the route itself, requiring a special unscheduled stop. Besides the discomfort and inconvenience of this situation, there are potential health consequences for the drivers, such as risk of urinary tract infection.

What we didn't see: The passengers
Our narrated trolley-bus ride was possible because the only "passengers" in the vehicle were our small group of researchers. Only by allusion did we get a glimpse of the complexities and difficulties entailed in driving a bus crowded with people. Just getting people on and off at each stop is a time-consuming challenge. Passengers often fail to realize how important it is for them to move to the rear so as not to block the driver's view. No one wants to be left behind because the bus is over-crowded, and the driver is inevitably the brunt of anger when this situation arises. Asking people to move back in the bus and explaining why no more passengers can come on, add to the driver's time and energy burden. On the other hand, unruly passengers may congregate in the back of the vehicle. Then, in addition to following the traffic situation, the driver must also keep an eye on the behaviors at the rear. This is a difficult task which can lead to compromises for safety of the passengers.

People in San Francisco rely on public transportation and expect punctuality. Passengers may enter the bus already upset by long waits and being late for their appointments, etc. A transit operator can be cited if a passenger complains. Our narrator described incidents in which "provocative" passengers complained about the transit operator's "attitude". Of major detriment to this situation is that the San Francisco urban transit operators have received an unfavorable treatment by the press. Unfortunately, bad press is not unusual for transit operators throughout the globe. The hard work of these drivers, to overcome so many obstacles and get people safely where they want to go, rarely if ever, makes the front page.

Danger-Threat of Violence
While varying in degree from one urban center to another, danger and threat of violence is a common and major stressor for this occupational group. The transit operator is vulnerable to violent attack at any moment; there are frequent reports of the driver being robbed at knife or gunpoint. The enormous social problems of urban society are often manifested in hostile acts directed against the transit operator. Carrying cash and transfers increases vulnerability.

Besides physical danger, frustrated persons often verbally vent their rage upon the transport operator. They may complain about the bad conditions in the vehicle itself, about which the driver is only more than well aware. The urban mass transit operator has, de facto, to be a kind of psychologist-to anticipate and handle all kinds of people and their troubles, and to devise coping strategies to minimize the disruption from these complaints.

On the other hand, interaction with the public is not only one of the major tasks of the mass transit driver, it also is frequently a source of satisfaction and gratification. Thus, suggestions for constructing compartments to separate the operator from the public in numerous settings including San Francisco, have met almost universally with opposition. The sentiments expressed were that this would feel like "cage" and create a sense of isolation and alienation. One, more human way out of this dilemma has been suggested by Drs. Kompier and DiMartino, i.e. that on certain lines, high-risk transport calls for two transport professionals on the line, instead of one. This proposal has been resisted by the companies because, they say, it would cost too much.

Time pressure
Inexorable time pressure is the modus vivendi of the urban transport operator. One's life becomes governed by the clock, and life is measured in time units of minutes. Waking for the morning rush hour passengers, often means rising at very early hours, sometimes two or three A.M. Scrupulously punctual drivers, fearful of not hearing the alarm, have reported to sleep lightly or not at all in anticipation of this early, strictly-defined awakening time. Running late, often not the fault of the driver, will compromise or eliminate the already short rest break which is scheduled usually at the end of the line. If the schedule is more severely compromised, some other kind of punitive measure may be taken. The driver is continuously pressing to catch-up with the schedule.

Dr. Greiner calculated that objective barriers took at least thirty extra minutes for nearly half of the four-hour work segments which she and her colleagues studied. The late Dr. Bertil Gardell eloquently described the fundamental conflict faced by urban mass transit operators: keeping on schedule versus providing to the immediate, specific needs of the public. This means not only answering questions, but also many other services, most notably, taking the extra time to accommodate the disabled and elderly.

Vigilance and avoiding accidents: Doubly burdensome for professional drivers
Even under the most ideal of circumstances, all driving requires high level vigilance to avoid accidents. The driver must continuously follow a barrage of incoming signals, to which he or she must be prepared to rapidly respond, whereby a momentary lapse of attention, or even a seemingly slight error or delayed response could have potentially disastrous consequences. For the urban transit operator this burden is much greater than for an amateur driver. For example, he or she must watch right-left-right-left before making any move, whereas the amateur driver usually makes just three visual direction shifts. An eye must be kept open for oncoming and exiting passengers and anyone at the side of the curb. There is a need to watch on the right far more than for amateur drivers. This can be one of the contributing factors to the high rate of neck and other spinal pain among professional drivers, which has been shown to be related to number of years in the occupation (witness the previously mentioned worn-down right side of the seat).

Furthermore, in situations for which an amateur driver would brake (or quickly change lanes or otherwise make some rapid maneuver), the urban mass transit operator must think about the fact that people are standing, there are frail passengers, or someone may be unsteady on his or her feet, and must try to maneuver accordingly. These dilemmas are obviously not always resolvable. If someone falls inside the vehicle, the transit operator is held liable. It should be noted that any one can stagger onto the bus, be unstable on his feet, etc. requiring yet extra vigilance for the transit operator. The biggest worry is always about an accident, whether big or small. Even a seemingly trivial accident may result in injuries to passengers.

Don't they just get "used to it"?
An easy assumption to make would be that with experience and time on the job, a city transit operator will adapt to these conditions, difficult as they may be. And it is true that the acquired coping skills and knowledge of a seasoned professional driver are irreplaceably valuable assets, without which it would be practically impossible to continue in this line of work. There is a high turnover rate among urban mass transit operators, such that those who stay on the job for ten or more years are a highly selected group.

However, a heavy price accompanies these years on the job. The very skills which get the driver through a working day are, in fact, a quiet displacement of the burden onto his or her target organs: the heart, the blood vessels, the gastrointestinal tract, the musculoskeletal system. It has been shown both in laboratory simulation and field studies that the experienced drivers who silently cope and seemingly automatically handle the continuous barrage of potential dangers and who toughly deny how difficult this work is, are those who show the most dramatic blood pressure and electrocardiographic responses to these threatening stimuli of the traffic environment. Reviews of the literature show that professional drivers are second to none as an occupational group at risk for hypertension and ischemic heart disease and that these diseases occur at a relatively young age. Several studies of heart attack patients under the age of forty report a marked overrepresentation of professional drivers, up to 40%, in some series. The published papers showing a high risk among this occupational group for cardiovascular and cerebrovascular disease, musculoskeletal disorders and/or peptic ulcer disease come from various parts of the world: from Europe, the U.S., Latin America, East Asia and the Indian subcontinent. A strong relation between number of years on the job and/or number of daily hours behind the wheel have been found in many of these studies.

The terrible human toll taken by these diseases, coming at an early adult age, also translates into enormous economic costs: absenteeism, disability and early retirement. It is unusual for a mass transit operator to retire at term in any city. In the Netherlands, for example, the average age of retirement for city bus drivers is 48 and is usually disability-based, with only 12% working until the normal retirement age of 60.

The Passengers
The bus drivers are not alone in experiencing stress while driving. Passengers in typical urban settings are exposed to a considerable number of daily challenges in using public transportation, beginning with frequent long waits for tardy vehicles, often in inclement weather. They enter the bus late for their destination, tired and perhaps ill or infirm, frequently to find standing room only. Buses are unsteady, stopping suddenly and lurching, making it difficult to remain stable on one's feet. Vehicles may be cold or overheated, and one may be pressed tightly against others. A single rowdy, or violent passenger can be frightening; the elderly and the otherwise frail are particularly vulnerable.

The reality is that public transportation is under-funded. Everyone is being forced to make due with less, and the consequence is that for both the driver and the passengers, a bus ride may result in a difficult time. Unfortunately, passengers and drivers may take out their frustration on each other, instead of directing these urgent concerns towards those who are in a position to implement the needed changes.

Is there a "way out"?
We have, in this short piece, only touched upon the myriad of stressful, noxious conditions in the urban transport operator's work environment. Quantitative analysis shows that the total burden of occupational stressors faced by the city bus driver is over twice that of construction workers and other trades which are known, in themselves, to be quite tough. Drs. Michael and Zoloth early in this decade signalled an urgent call to implement specific interventions designed to reduce occupational stress among urban transport operators. But how?

In fact, worldwide, there are a number of major efforts in this direction. Drs. Kompier and DiMartino, as has Dr. Evans, have published an inventory of potential strategies to prevent bus drivers' stress. There is a general consensus among experts in this area that limiting the number of hours behind the wheel, guaranteed rest breaks and diminishing time pressure are absolutely essential minimal requirements for all urban transit operators. More attention to the special health needs of professional drivers, and primary prevention programs are also necessary.

One innovative effort to improve the working conditions of bus drivers has taken place in Stockholm, Sweden. The focus was upon the toughest bus route in the city. Some parts of the route's street were widened, a special bus lane was created for a large portion of the route, and a number of other changes were instituted. There appear to be some benefits in terms of blood pressure and other physiologic measures among a small group of drivers who were examined before and after the changes were made.

However, the narrow, hilly streets of San Francisco, and many other specific characteristics of that city call for a different approach. Named the "Ambassador Program", and with the explicit aim of bringing "hope to Muni operators and riders", a concerted effort is underway to improve conditions for both of these constituencies. This program was brought about by the joint efforts and agreement of the Transport Workers' Union Local, the San Francisco Municipal Railway, together with representatives of the transport riders, and with the input of physicians and other researchers with expertise and concern about the health and well-being of the urban transport operators.
The basic elements include:
--increasing the number of transit operators to full strength,
--revising schedules to be more realistic and to guarantee recovery time
--improved equipment, i.e. providing working vehicles
--upgrading and training of the operators, to provide "transportation-service rather than merely moving a vehicle from one place to the other". Experienced operators would be offered the opportunity to become "line-trainers", and from this venerated position, provide guidance and share their skills with their colleagues.

Furthermore, efforts are being made to have the operator drive on the same line as much as possible. This has been a major Trade Union demand, allowing the operator to become familiar with his or her environment: with the passengers and all the specifics of the route. Knowing what to expect improves the level of the transit operator's control, and this is a key part of healthy-work practice.

Dr. June Fisher has stated that the urban transit operator represents the "eyes and the ears of the city". Stated another way, the troubles of the urban transit operator are the troubles of us all in the city. But, the corollary would read: the health of the city transit driver, is inextricably linked to the health of the city. Efforts in the latter direction are therefore in the interest of us all.

Acknowledgements:

The authors would like to thank Drs. June Fisher, Birgit Greiner, Niklas Krause and Paul Landsbergis for reviewing this paper and providing helpful suggestion. We are grateful for the opportunity provided by the Transport Workers' Union Local and the San Francisco Municipal Railway to participate in the narrated ride along Line 22. We appreciate the time and energy which the transport operators themselves devoted to this endeavor. The tour was organized by June Fisher, M.D., and was based upon the long-standing, on-going interactions between the researchers from the Muni Health and Safety project with Muni management, the Transport Workers Union local and the individual transit operators in the system.

For Further Reading on the Working Conditions and Health Risks among Urban Transit Operators
Studies of Urban Mass-Transit Operators: Special Issue of Journal of Occupational Health Psychology. 1998; 3 (2).

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