Hazards issue 88, October-December 2004
When film star Julie Andrews announced in 2004 her vocal cords were permanently damaged and she would never sing again, it made international headlines. For millions of workers in the UK, their voices will not be their fortune, but they are their bread and butter, and voice loss could also spell the end of their careers.
About one-third of the workforce in modern economies relies on their voice to do their job, from teachers to trade unionists, call centre workers to checkout staff. And as the service sector continues to grow, the impact of "repetitive voice injury" on workers and the economy could be enormous.
A quarter of the workforce experiences daily voice problems, according to a US report. In the UK, the Health and Safety Executive (HSE) has no figures on the extent of occupational voice loss, however an estimate based on the US figures would suggest over 5 million workers are routinely affected by voice loss in the UK, at an annual cost to UK plc of over £200 million.
HOARSE FOR COURSES
College lecturer Donny Gluckstein, a
union rep with Scottish teaching union EIS, lost his voice last
year. Filling in for absent colleagues and running an intensive
course "made me hoarse to the point where even speaking gently
was painful," he said. A visit to his GP confirmed he had "aphonia"
due to work-related overuse.
Armed with a sicknote, he asked for "reasonable adjustments" to be made at work. "Being a union health and safety rep and health and safety lecturer and getting advice from the EIS health and safety official was very useful," he said. Management responded positively. However, even with the aid of a radio mike, laptop and projector, his voice became too weak to speak. He continued teaching, silently, with the help of portable whiteboards and the laptop.
Donny's voice only started to improve when he finally got to see an ear, nose and throat specialist, who said instead of rest he needed exercise supervised by a speech therapist. He still uses the laptop and projector, has dropped intensive classes, and has his remaining classes spread over the week to avoid long periods of unbroken teaching. And he wants to ensure others learn from his painful lesson. "Our safety committee discussed voice care and management is already liaising with other local further education colleges," he says. "One teacher training college even asked me for advice on how to get voice training up and running.
"So the lesson is - don't suffer in silence. There is a duty of care and a lot that can be done for the most valuable tool in the teacher's toolbox - their voice."
Click here to read Donny's story
One in five teachers had missed work due to voice problems in any one year, five times the rate for the workforce as a whole, 1998 study found. For the non-teaching workforce, an occupational disease incidence rate of one in every 50 workers each year would put occupational voice loss near the top of the UK's workplace health hit list.
And we are talking large numbers of at risk workers. The Call Centre Management Association puts the number of UK call centre workers in 2004 at 1 million. And government figures for 2004 said there were 427,800 teachers in England alone.
When questioned by Hazards, teaching, call centre, banking and industrial unions all reported occupational voice loss was a concern for their membership. And it is not a trivial problem - too much talking in the wrong environment can cause permanent damage, and could cost you your job.
What jobs are we talking about?
The range of workers potentially at risk of occupational voice loss is wide and includes:
Teachers, lecturers, childcare workers
Salespersons - shopworkers, sales staff, demonstrators, auctioneers, counter staff
Barristers, preachers, politicians, trade unionists
Drill sergeants and other NCOs
Journalists, radio and television reporters
Entertainers - singers, actors, performers, bingo callers, line dance callers
Call centre workers
Receptionists, advice line workers, counsellors, interviewers
Aerobics, fitness instructors, coaches
As the service sector grows, more and more workers are depending on their voice to earn a living. Call centres are one of the UK's fast growing areas of employment and could now employ more than one in every 50 UK workers. And the new jobs have been accompanied by an outbreak of "call centre-itis".
According to the Royal College of Speech and Language Therapists, increasing numbers of call-centre workers are being referred to speech therapists because they are losing their voices. Long hours and little opportunity for even a drink of water are to blame. "It's a growing problem," said Paul Carding, a professor of voice pathology and national adviser to the college. "There is increasing evidence of people taking time off because if they can't use their voice they can't work. At its most severe these people can't hold down a job. They have pushed their voice to the absolute limit. In some cases, voices really struggle to recover."
Teachers remain the most common professional group to require speech therapy, but call centre workers have now become the fastest growing "at risk" sector. The call centre industry says it shouldn't be singled out, saying other jobs can also lead to the condition.
Listen to your voice
Early signs of a problem might not seem too worrying or unusual - discomfort speaking, a lower pitch to the voice, breaking voice, a loss of vocal range, a tickling in the throat, or an urge to cough or clear the throat, or a voice that becomes harsh, raspy, shrill or thin. This will normally sort itself after a break - a night's sleep or a weekend off. But if the symptoms persist, this could be the early signs of a long-term and potentially irreversible problem. The onset may be gradual, so it is important to be vigilant for signs the symptoms are becoming more frequent or more troublesome.
In severe cases, vocal strain can produce inflammation of the larynx, swelling of the vocal chords or the appearance of vocal nodules, tumours or ulcers. In its guidance on call centre health and safety,  HSE says: "The medical term for voice problems is dysphonia. The condition is not just an inability to speak but also includes pain, tension, croakiness, irritating cough, inability to modulate, poor or no vocal power and breathing difficulties."
A lot of different medical terms might end up on your sicknote if your voice has been worked too hard.
• Aphonia - inability to speak.
• Dysphonia - voice loss, hoarseness.
• Odynophonia - pain and soreness in the throat with prolonged vocal use.
• Hyperaemia of the free edges of the vocal chords - common in singers and speakers and could become chronic.
• Vasomotor chorditis - chronic congestion, usually limited to one vocal chord. Aggravated by vocal effort. Partly reversible.
• Nodules and polyps of the vocal cords.
• Laryngeal contact ulcers.
• Hyperplasia of the vestibular folds.
• Pseudomyxomatous laryngitis.
If you think you have a problem, get it checked out. See your GP and explain fully what job you do, how much you use your voice, say if you are under pressure. Remember you know more about your job than your doc - they are generalists. If the problem persists, make sure you get a referral to an ear, nose and throat specialist or a voice clinic - there is a national network of clinics with expertise in this area.
Click here for guidance: "Identifying when medical advice may be needed"
No laughing matter - workplace risk factors
While talking might not be avoidable in some jobs, voice loss is. Bad workplaces and workloads make this a workplace problem. Key factors that can lead to occupational voice loss are:
Overuse Voices aren't designed to talk continually without breaks, and cannot cope with prolonged heavy use without breaks, for example, singing or shouting.
Noise In most of the workplaces with a high risk, there tends to be little thought given to acoustics because there is not usually an occupational deafness risk. However, we raise our voices causing vocal strain when the background noise level gets about 40dB, a fraction the occupational exposure limit, so the voice struggles even though the ears are fine.4
Humidity and temperature Low humidity, particularly prevalent in winter, is bad for the vocal cords and leads to an increased risk of throat irritation and infections.
Stress Your throat is affected by stress - hence, the telltale "lump in the throat". In extreme cases, this can cause "hysterical aphonia", stress-induced voice loss.
Fatigue As the voice gets tired, it falls off, so extra effort is needed to make yourself heard. This can be the start of damaging cycle of overuse.
Infections Colds and flu must be taken seriously - a sore throat is a warning sign that the larynx is inflamed and needs a break.
Air quality Poor workplace air can cause irritation - mould spores in damp environments, airborne dusts like glass fibre, aluminium, wood dust, silica, lime. "Hemp workers' laryngitis" is a recognised occupational disease. For teachers, chalk dust or marker fumes can cause problems.
Chemicals Some common workplace exposures - chlorine, nitrogen oxides, aromatic nitro-compounds, organic solvents, bitumen fumes - can affect the voice.
Work methods Power dialling systems, large classrooms, long scripts for call centre workers and too few breaks are among the management causes of workplace voice loss.
Strain injuries The use of speech recognition software as a response to RSI problems can switch the strain to the voice, unless adequate breaks are built in to the job.
All of these factors should be considered in the employer's risk assessment of a job and reasonably practical measures should have been taken to remedy the risk.
Speak up! Checklist for safety reps
Occupational voice loss can be disabling condition - and in workplaces like schools and call centres, it is possible a large proportion of the workforce is affected. It is management problem, not a personal problem.
Investigate Find out if there is a problem in your workplace - have you undertaken bodymapping, risk mapping or a workplace survey that has indicated a problem? www.hazards.org/tools
Risk assessment Check that workplace risk assessments have been carried out by your employer. Remember, the law says that employers should carry out "suitable and sufficient" risk assessments on the jobs you do - and that means being aware of any voice loss risk and taking "reasonably practicable" measures to tackle them.
Accident book List cases of voice loss in the accident book - and make sure you raise any dangerous trends you spot.
Max hours Negotiate an agreement for set maximum hours of voice-based work per day.
Noise Ensure your employer reduces the levels of background noise so you do not have to raise your voice to be heard.
Welfare Take regular rest breaks and drink plenty of fresh water to lubricate your throat (caffeine and alcohol are drying agents). TUC's Worksmart guide notes: "If you are also not using your voice properly, so that it is already under strain, then speaking with dry vocal cords for extended periods of time is likely to cause injury. It's like not having any engine oil in your car."
Stress Negotiate working patterns which reduce stress levels - the Approved Code of Practice to the Management of Health and Safety at Work Regulations requires that employers "adapt work to the individual" including modifying working methods and designing out "monotonous work and work at a pre-determined rate."
Environment Ensure your employer provides a working environment which is at a comfortable temperature and humidity (Workplace Health, Safety and Welfare Regulations 1992).
Pollution Ensure your employer has controlled dust and chemicals properly, as they can dry and inflame the mucous membranes of the vocal tract.
Sick leave Don't be part of the working wounded - overworking a throat that is already sore, through exertion or cold or flu, can cause long-term damage.  Make sure your sick leave agreement isn't allowing ill workers to be frog-marched into work (Hazards 85).
Make them listen
HSE's only guidelines on voice loss comes in its calls centres advice document.  It says: "The introduction of any good practice for voice health which may substantially affect the health and safety of call handlers should be done in consultation with call handlers or their representatives."
It adds: "Call centre employees should be provided with information on the risk of dysphonia, the various symptoms of the condition and how this risk can be reduced."
HSE gives these good practice pointers:
To reduce the risk of straining the throat, opening greeting scripts should be broken into shorter segments, giving call handlers frequent micro-breaks while callers respond to their questions.
Allow call handlers to drink at their workstations to ensure their throats are adequately lubricated.
Call handlers should be encouraged to drink water or caffeine-free soft drinks to maintain hydration rather than tea or coffee or soft drinks containing caffeine - these which are diuretics.
Stretching the neck and shoulders relieves tension. Exercises can be done at the workstation as well as during breaks. A prompt which appears on the screen from time to time may be a helpful reminder for call handlers to do these stretches.
The risk of voice problems is greater when suffering from a cold. Assigning staff in these circumstances to tasks which do not involve speaking on the telephone reduces this risk.
Unifi, the finance workers' union, says "risk assessment should be seen as a key element in helping reduce the incidence of voice loss." If your employer hasn't completed a "suitable and sufficient" risk assessment on your job, then your employer is breaking the law.
Unifi suggests the following negotiating points for safety reps, particularly those whose members work in call centres or on advice lines:
Change work routines and introduce work variety and changes to the pace of work.
Provide better quality headsets if equipment is faulty.
Provide voice care training.
Allow regular work breaks away from the phones.
Monitor reasons for sickness absence, to spot cases of sore throats and coughs which are caused by work, and encourage staff to swap to other duties until they recover.
Make improvements to air humidity, temperature and circulation.
Offer suitable alternative employment for employees suffering permanent voice problems.
£92,000 voice loss pay out
Peter Hilton, a member of the rail union TSSA, worked for Regional Railways as a training instructor. He often had to lecture inside a depot while engines were running, so he had to compete with noise and diesel fumes from the engines.
During 1992, Peter found his voice was becoming hoarse. More and more often, he had to reach for a glass of water to continue lecturing. His GP sent him to a consultant, who diagnosed chronic laryngitis. By this stage, Peter was often unable to work because of the state of his throat.
Peter contacted TSSA and the union put its legal team into action. First TSSA lawyers got a consultant's report, which confirmed that the laryngitis was caused by the fumes in the depot combined with the volume at which Peter had to speak.
The lawyers then obtained a consultant chemist's report on the fumes and an engineer's report on the level of background noise. These reports indicated that while the fumes certainly hadn't helped Peter, straining to be heard against the noise was the main cause of his problem.
The union started legal proceedings in November 1995, after Peter was forced to retire through ill-health in April 1994 at the age of 59. Peter had planned to work until he was 65 and then take a part-time position teaching at night school, but his throat problem put that out of the question.
The case came up for trial in January 1999. TSSA lawyers produced more medical reports showing that Peter's condition was now permanent. Before the trial, BR's solicitors offered to settle the case for over £70,000, but TSSA's lawyers believed Peter was owed much more.
After negotiating with BR's lawyers, the TSSA team got the offer increased to £93,775, which Peter accepted. Even at that point, he wasn't out of the woods. The Department of Social Security wanted £23,775 of the compensation back from Peter.
TSSA's lawyers successfully appealed and Peter has secured over £92,000 to make his retirement closer to the one he had a right to expect. 
It's official! Teacher gets the benefit
Teaching union NUT has represented many members struggling with occupational voice loss. In one key case it set a precedent, getting the condition recognised by the government in 1995 as an occupational condition and eligible for industrial injury benefits.
Patricia Clowry, a teacher for 19 years at a Newcastle-under-Lyme primary school, began to lose her voice when her class size was increased to 44. She needed three operations on her vocal cords and had to leave her job.
Mrs Clowry had kept a diary and recorded incidents when the classroom was particularly noisy. Her voice was always worse towards the end of the week than at the beginning. She related her voice "injury" to a series of "accidents" - particular days when she had to strain and suffered voice problems.
A Social Security Appeals Tribunal agreed she was entitled to compensation. It ruled "the appellant had suffered an accident or a series of accidents which would have occurred on a distinct occasion or occasions."
The tribunal explained the reason for its decision: "We are satisfied that the strain of teaching a much larger class of children of a younger age than she had been used to put a strain on her voice but more so it was after particular days when the children were extra difficult or more lively that she suffered either an accident or a series of accidents to her voice because of the extra difficulties in raising her voice to cope with the children on those days."
In order to get a government Industrial Injuries Benefit payout, Mrs Clowry had to prove she had suffered an "accident". The scheme only pays out for "accidents" or an inclusive list of occupational diseases, which does not include voice loss.
Patricia Clowry, Social Security Appeals Tribunal, Ref. no. 410 95 02050, 12 April 1995.
1. E Vilkman. Voice problems at work: A challenge for occupational
health and safety arrangement, Folia Phoniatrica et Logopaedica, vol.52,
pages 120-125, 2000. [Abstract]
2. K Verdolini and Lorraine O Ramig. Review: Occupational risks for voice problems, Journal of Logopedics, Phoniatrics, and Vocology, vol.26, pages 37-46, 2001. [Abstract]
3. E Smith and others. Frequency of voice problems among teachers and other occupations, Journal of Voice, vol.12, no.4, pages 430-388, 1998.
4. E Rontal and others. Vocal cord dysfunction - an industrial health hazard. Annals of Otology, Rhinology and Laryngology, vol.88, pages 818-21, 1979.
5. Voice in the teaching profession, The General Teaching Council for Scotland [pdf]
6. TSSA journal, April/May 1999.
7. Advice regarding call centre working practices, Local Authority Circular 94/1 rev, Health and Safety Executive/Local Authorities Enforcement Liaison Committee (HELA), December 2001.
Hazards voice loss webpage: includes resources and union guides.
Hazards tools - guides to surveys, bodymapping, risk mapping and other workplace hazard assessment tools. www.hazards.org/tools
Hazards workplace sickness guide: Union resources on workplace sickness absence policy www.hazards.org/sickness
Voice Care Network UK, 29 Southbank Road, Kenilworth CV8 1LA. Publishes
newsletters and runs voice care clinics. It publishes a newsletter, VoiceMatters.
A booklet, More Care for Your Voice, is available from the Voice Care
Network, tel: 01926 864000 or 01926 852933, price £4.
British Voice Association, Institute of Laryngology and Otology, 330
Gray's Inn Road, London WC1X 8EE. Expert body on voice loss and has a
national network of NHS voice clinics. Tel:020 7713 0064
The Royal College of Speech and Language Therapists, 2 White Hart Yard, London SE1 1NX, tel: 020 7378 1200. Can provide advice on voice loss clinics.
NUT health and safety briefing: Keep the noise down [pdf]
TUC Worksmart guide to occupational voice loss.
• Hoarse for courses
• What jobs?
• Call centre-itis
• Listen to your voice
• Dangerous talk
• No laughing matter
• Speak up!
• Make them listen
• Union wins £92,000
• Teacher gets the benefit
Donny's story more
Identifying when medical advice may
be needed more