SN Comprehensive Clinical Medicine https://doi.org/10.1007/s42399-020-00441-7 MEDICINE A Comparative Study of Prevalence of Morbidities among Municipal Solid Waste Workers in Mumbai Pradeep S. Salve 1 Accepted: 28 July 2020 # Springer Nature Switzerland AG 2020 Abstract Paper investigates the association between labour intensive work of solid waste collection and street sweeping with the development of skin disease, respiratory disease, eye infection, musculoskeletal disorders (MSDs) and MSDs-related disabilities during the service. A primary survey was conducted with 540 municipal employees adopting multistage stratified systematic sampling in 6 out of 24 municipal wards in Mumbai. The data was collected between March and September 2015, and analysis was performed in STATA13. The prevalence of self-reported morbidities among municipal workers varies from 7 to 46% in the reference period of the past 6 and 12 months. Adjusted odds of major morbidities show that the waste collectors significantly more likely to have injury/accident (OR = 11.36; p < 0.01), skin disease (OR = 4.971; p < 0.01), eye infections (OR = 3.03; p < 0.01) and MSDs (OR = 2.04; p < 0.05) in reference to comparison group. Similarly, street sweepers significantly more likely to have injury/accident (OR = 4.08; p < 0.01), skin disease (OR = 4.50; p < 0.01), respiratory disease (OR = 2.63; p < 0.01), MSDs (OR = 2.17; p < 0.01) and disability (OR = 1.92; p < 0.05) in reference to comparison group. Propensity score matching method analysis suggests that the waste collecting and street sweeping occupation significantly increases the prevalence of morbidities among exposed workers than the matched non-exposed workers. The mean expenditure on treatment of morbidities show that street sweepers spends significantly (p < 0.05) higher amount of money for injury/accident, eye infections and MSDs followed by waste collectors compared with comparison group. Workers associated with the street sweeping and waste collecting occupation has higher burden of developing morbidities and health expenditure compared with other occupation. Keywords Municipal solid waste . Waste collector . Street sweeper . Musculoskeletal disorder . Mumbai Introduction The management of solid waste generated by the overcrowded population in metropolitan cities encompasses a wide range of activities including waste collection, transportation of collected waste to the disposal field, sorting recyclable materials and disposing off before it pollutes environment. In developing countries, solid waste management (SWM) department is mainly labour intensive and required continues engagement. Waste collectors in developing countries manually handle the solid waste and dump community garbage containers into the operational trucks. These workers are at the risk of This article is part of the Topical Collection on Medicine * Pradeep S. Salve pradeep8889@gmail.com; pradeep_salve@biari.brown.edu 1 Population Research Centre, JSS Institute of Economic Research, Dharwad, Karnataka 580 004, India development of health problems during waste collection on the field, transportation of collected waste and recycling and disposal on landfill. About 90% of municipal solid waste (MSW) disposed unscientifically in open grounds and manage improperly creating landfills in India [33]. Mumbai is the capital of garbage generation which contributes 8069 metric tons of waste and 2266 metric tons dry solid waste per day in 24 administrative wards of the Municipal Corporation of Greater Mumbai (MCGM) [5]. Approximately 3.77 million tons of solid waste systematically reclaimed on landfill by workers during the year 2013–2014. The huge labour force of 35,100 including 28,018 formal and 7000 informal employees such as waste collectors and street sweepers are working in the SWM of Mumbai every day [9, 25]. Considering at the national level, this number of labour force may increase in multiple folds with possible vulnerabilities of developing health risk. As the waste collection is labour intensive, it involves considerable heavy lifting, pulling, pushing and manual handling of heavy containers which increases the risk of health hazards. Previous studies found that work-related health problems like SN Compr. Clin. Med. respiratory disease, skin infection, eye flu and gastrointestinal disorders are more common among workers engaged in SWM compared with the general workforce [26, 28]. Similarly, studies conducted in Danish, Taiwan and Florida found that SWM workers are more exposed to chronic respiratory problems, musculoskeletal disorders (MSDs), injuries caused by sharp objects, strains/sprains, contusions, fractures and dermal problems than other workers [15, 16, 18, 22, 36]. Further, studies conducted in developing countries depicted the high prevalence of MSDs including low back pain, knee pain and shoulder pain due to the heavy and repeated physical activities compared with the general population [1, 24]. In the Indian context, the study conducted in Gujarat involving 292 waste collectors and 93 workers working in back offices highlighted that waste collectors have potential risk for the development of chronic respiratory symptoms, MSDs and injuries compared with the other workers [19]. Similarly, morbidities such as anaemia, hypertension, upper respiratory tract infections and chronic bronchitis found to be higher among street sweepers than the comparing group [29, 34]. The survey conducted in Kerala found out that respiratory diseases, eye diseases, dermatological problems, nail infection/injury and water vector-borne disease were common to workers [20]. Likewise, the study carried out in Chandigarh with municipal street sweepers, waste collectors and waste processing workers is the evidence that workers mainly suffered from the respiratory problems (coughs and breathlessness), injuries, vomiting and MSDs [27]. Multiple and frequent episodes of morbidities among municipal workers cause the economic burden during the treatment-seeking behaviour. Particularly in developing countries, episodes of out-of-pocket expenditure (OOPE) on health cause indebtedness and lead to financial burden of health expenditure on family which subsequently force people into below poverty line. Households having financial burden due to poor health condition used the combination of savings, borrowing money and selling consumable assets as a coping strategy [4, 30, 35], although there are past studies that identify the vulnerability of developing various fatal and catastrophic morbidities among MSW workers [19, 27, 29]. But in addition to this, our study attempts to refill the research gap by highlighting the major morbidities and OOPE during treatment of respective morbidities. Particularly, the present study compared the morbidity condition and incurred OOPE among waste collectors and street sweepers with comparison group workers in MCGM. Materials and Methods This study is based on the primary survey which was conducted with MSW workers engaged in waste collecting and loading it into the garbage compactors (waste collectors) and street sweepers in 6 out of 24 municipal wards in MCGM. A group of workers was selected as the comparison group has more or less similar socioeconomic characteristic but not exposed to street sweeping or waste collection [14]. The non-exposed comparison group of workers includes back-office personnel, peons and ‘D’ class employees at various municipal offices. Considering their socioeconomic characteristics, we have selected them as the comparison group workers which represent the general population. The sample size was determined using the prevalence of major morbidity that found among MSW workers in Indian context. The cross-sectional study conducted with SWM workers in Kerala reported that the prevalence of major morbidities varies from 30 to 47%. The prevalence of eye disease (30%) was the lowest among major morbidities; therefore, the expected prevalence of morbidity was consider at least 30% for the sample estimation [20]. The determined sample size was calculated using formula given by Cochran [6]. The determined sample size for a group was 180 workers, and therefore, three groups were 540 workers. The survey was carried out by employing multistage stratified systematic sampling design; at the first stage, 24 municipal wards were arranged in the ascending order of percentage of slum population in respective wards. Then it was stratified into 3 strata with low, middle and highest slum population. Each stratum includes a total of eight wards, and out of eight wards, we randomly selected 2 wards as the representative of other wards in that strata for our sample selection. Finally, 90 workers systematically (30 waste collectors, 30 street sweepers and 30 compare group) selected from each ward with the help of the listing provided by MCGM. The inclusion criteria for workers in the survey were at least 5 years working experience in the SWM department of MCGM. Interviews were conducted according to the availability of workers at their working places during March to September 2015. The statistical software was used for the primary data entry (CSPro 6.0) and statistical analysis (STATA 13). The standardized questionnaires such as American Thoracic Society and the Division of Lung Disease (ATSDLD-78) and Standardized Nordic Questionnaire (SNQ) were used to cover the different morbidities among workers. The ATS-DLD-78 inquires the chronic respiratory symptoms like coughing, wheezing, shortness of breath, chronic bronchitis, asthma and TB symptoms in past 6 months [7], whereas the SNQ covers the MSDs symptoms which includes the pain in nine anatomical parts such as pain in the neck, shoulders, upper back, elbow, lower back, knee, hip/thigh and wrist/ hand with the reference period of past 7 days and 12 months [21]. The morbidities are self-reported and recoded based on the response of the workers. In the past 12 months, workers prevented from doing day-to-day normal activities at home or away from home due to MSDs were recoded as disabled. Subsequently, questionnaire covers detail expenditure on the SN Compr. Clin. Med. treatment during the illness including money spend on the doctor’s fees, surgery, medicine, X-ray-ECG-EEG, transportation and other expenditure during the illness. In addition to this, the detail information on substance use, mental health, job satisfactions and socioeconomic characteristics were also covered. The descriptive statistics were used to access the occupational and socioeconomic characteristics of MSW workers. Further, the Chi-square test was applied to assess the association between type of workers, morbidities and the background characteristics of workers. To examine the burden of expenditure during treatment seeking, the one-way ANOVA was employed at the 5% level of significance among three groups of workers. In case of significance of ANOVA test, post hoc (Tukey’s) test was performed to test the significance between the group differences. Additionally, the study adopted the nearest neighbourhood method of propensity score matching (PSM) to assess the exposure of the street sweeping and waste-collecting occupation on the development of morbidities. The PSM analyses the causal relationship between the occupation of individual and its related morbidities by controlling the matched socioeconomic, occupation and demographic variables. Further, to understand the individual risk factors of morbidity and disability among street sweepers and waste collectors, multiple logistic regression analysis was performed. Ethical Consent This paper is a part of the PhD thesis work conducted during 2013–2018 in the International Institute for Population Sciences (IIPS). The prior permission for data collection was taken from the MCGM. The ethical clearance certificate was approved by the Ethical Review Committee of IIPS (SREC12/ 3144) prior to field work. While conducting the survey on the field, full confidentiality of information was maintained, and workers were assured about the secrecy of information shared during the interviews. Results Socioeconomic Characteristics Table 1 presents the descriptive statistics on demographic and socioeconomic characteristics of study group by type of occupation. The mean age of workers working in municipal corporation found to be more or less similar among waste collectors (36 years), street sweepers (37 years) and the comparison group workers (38 years) (Table 1). Similarly, the mean years of working of waste collectors (10 years) and street sweepers (10 years) found to be similar to the comparison group workers (11 years). Majority of waste collectors (60%) and street sweepers (60%) have less than 10 years of schooling than the comparison group workers (9%). More than threefourths (78%) of waste collectors followed by street sweepers (86%) belong to the scheduled castes compared with the comparison group workers (52%). The prevalence of substance use was found to be high among workers; for instance, 47% of waste collectors followed by street sweepers (44%) consumed alcohol compared with comparison group workers (22%). Majority of the comparison group workers belong to the rich standard of living index compared with the waste collectors (19%) and street sweepers (31%). Occupational-Related Morbidities Table 2 presented the prevalence rate of major morbidities among municipal workers which varies from 7 to 46% in the past six and 12 months. Results distinctly depicted that the waste collectors have a higher prevalence of injury/ accident (43%), skin disease (18%), respiratory disease (18%), eye infections (24%), MSDs (45%) and disability (36%) followed by street sweepers (25%, 19%, 29%, 14%, 46% and 43%) compared with the comparison group workers (8%, 7%, 17%, 14%, 33% and 32%, respectively) (Table 2). The street sweeping and waste collecting occupation are stinky and dangerous work performed by municipal workers in the different urban areas in India. The prevalence rate of injury/accident found to be high among waste collectors, and in the case of street sweepers, the respiratory-related diseases found to be higher than waste collectors and comparison group workers in the past 6 months. The possible causes may be due to the exposure of dust particles and air pollution on the public roads. Looking at the respiratory disease, street sweepers were more vulnerable for developing the respiratory infections than the waste collectors and comparison group workers during the past 6 months. Particularly, the prevalence of asthma (21%), chronic cough (14%), continuous running nose (13%) and breathlessness (28%) found to be higher among sweepers compared with the waste collectors (9%, 8%, 3% and 12%) and comparison group workers (12%, 8%, 8% and 16%), respectively. The waste collectors and street sweepers found to be more vulnerable for development of MSDs due to the continuous activities of pulling, pushing and lifting of heavy waste materials and community dust bins. In particular, street sweepers reported higher prevalence of pain in the upper back (34%), low back (33%), shoulder (32%), wrist/hand (29%), elbow (27%), hip/thigh (27%) and neck (17%) followed by waste collectors (32%, 39%, 26%, 19%, 11%, 19%, and 13%) compared with the comparison group workers (27%, 29%, 11%, 19%, 9% and 11%), respectively, in last 12 months. Similarly, workers engaged in street sweeping occupation reported the higher prevalence of MSDs-related disabilities for the upper back SN Compr. Clin. Med. Table 1 Demographic and socioeconomic characteristics of study groups by type of occupation Characteristics Type of workers Waste collectors Street sweepers Comparison group 19–34 35–58 Mean age ± SD Year of working p < 0.01 Less than 10 years Above 10 years Mean years of working ± SD Years of schooling p < 0.001 Non-literate Less than 10 years Above 10 years Mean years of schooling ± SD Marital status p < 0.04 Currently married Other* Caste p < 0.001 SCs/STs None of above Mean net salary ± SD 53.3 46.7 36 ± 8.6 45.6 54.4 37 ± 9.1 34.4 65.6 38 ± 7.4 67.8 32.2 10 ± 7.9 60.0 40.0 10 ± 8.5 51.1 48.9 11 ± 6.5 10.6 49.4 40.0 8 ± 3.7 14.4 45.6 40.0 8 ± 4.1 0.0 8.9 91.1 12 ± 2.2 92.2 7.8 88.3 11.7 95.6 4.4 78.3 21.7 12,105 ± 4741.1 85.6 14.4. 11,487 ± 4007.1 51.7 48.3 16,511 ± 3711.6 Mean gross salary ± SD Substance use Smoking Alcohol Tobacco Job satisfaction p < 0.001 Good Average Bad Body Mass Index p < 0.05 Underweight Normal Overweight Mean BMI ± SD Standard of Living Index p < 0.001 Poor Middle Rich 20,809 ± 4188.9 21,219 ± 4624.8 22,391 ± 3982.4 17.8 47.2 46.1 11.7 43.9 46.1 11.1 21.7 34.4 17.2 58.9 23.9 17.8 65.0 17.2 30.6 61.1 8.3 6.1 61.1 32.8 23.52 ± 3.4 6.7 58.9 34.4 23.62 ± 4.4 1.1 50.6 48.3 25.14 ± 3.4 46.1 35.0 18.9 37.2 32.2 30.6 16.7 33.9 49.4 N = 180 N = 180 N = 180 Age p < 0.001$ Total $, p value of Chi-square; SCs, scheduled castes; STs, scheduled tribes; OBCs, other backward castes; other*, not married and widowed/widower; , Rupees; ± SD, standard deviation (27%), low back (27%), wrist/hand (26%), shoulder (24%), elbow (23%), hip/thigh (17%) and neck (11%) followed by waste collectors (25%, 31%, 14%, 16%, 5%, 23% and 6%) compared with the comparison group workers (19%, 18%, 13%, 9%, 6%, 8% and 9%), respectively. Table 3 present the adjusted odds ratio for major morbidities by type of workers. Results depicted that the waste collectors significantly more likely to have injury/ accident (OR = 11.36; p < 0.01), skin disease (OR = 4.971; p < 0.01), eye infections (OR = 3.03; p < 0.01) and MSDs (OR = 2.04; p < 0.05) in reference to the comparison SN Compr. Clin. Med. Table 2 Prevalence of morbidities among study groups in past 6 and 12 months Morbidities Waste collectors Street sweepers Comparison group Injuries/accident# Fracture @ Laceration* @ Contusion on job @ Other injury @ 43.3 15.6 36.6 14.4 13.3 25.0 2.2 20 2.7 7.7 8.3 1.1 2.7 5.6 2.7 Skin disease Rashes/infective Itching Dermatitis Respiratory disease Dust allergy Dyspnoea Episode of asthma Chronic cough Running nose Breathlessness Eye Soreness/infection Redness Watering Itching MSD$ Neck 18.3 13.8 14.4 9.4 17.7 2.2 2.8 9.4 7.8 3.3 11.6 24.4 14.4 17.7 18.8 13.3 45.0 13.3 18.8 9.4 17.2 14.4 28.8 3.3 3.3 20.6 13.8 12.7 27.7 13.8 5.0 7.7 12.2 12.2 46.1 16.7 6.6 3.8 6.1 4.4 16.6 1.1 2.2 12.2 7.7 8.3 15.5 14.4 7.2 8.8 12.2 10.5 33.3 10.6 Shoulder Elbow Wrist/hand Upper back Low back Hip/thigh Knee Ankles/feet Disability$ Elbow Wrist/hand Upper back Low back Hip/thigh Neck Shoulder Knee Ankles/feet 26.1 10.6 18.9 31.7 38.9 34.4 3.3 3.3 36.1 5 13.9 25 30.6 22.8 5.6 15.6 2.2 1.7 31.7 26.7 29.4 33.9 33.3 26.7 1.7 3.9 43.3 23.3 26.1 26.7 26.7 16.7 10.6 24.4 0.6 1.7 11.1 8.9 18.9 27.2 29.4 20 3.9 2.2 32.2 5.6 13.3 18.9 17.8 7.8 9.4 9.4 3.3 2.2 Total 180 180 180 @, health conditions; *Laceration with needles and glass materials; #Due to multi-response question, total will not be add up to 100%; MSDs, musculoskeletal disorders, Disability; $ reference period past 12 months group workers (Table 3). Similarly, street sweepers significantly more likely to have injury/accident (OR = 4.08; p < 0.01) followed by skin disease (OR = 4.50; p < 0.01), respiratory disease (OR = 2.63; p < 0.01), MSDs (OR = 2.17; p < 0.01) and disability (OR = 1.92; p < 0.05) in reference to the comparison group workers. SN Compr. Clin. Med. Table 3 Adjusted odds ratio for major morbidities by the types of workers Characteristics Injury/ accident $ Types of workers Comparison group® Waste 11.36*** collectors (5.07–25.44) Street 4.08*** sweepers (1.87–8.89) Skin Respiratory Eye MSDs Disability 4.97*** 1.24 3.03*** 2.04** 1.32 (1.90–13.00) 4.50*** (0.56–2.74) 2.63*** (1.41–6.51) 1.35 (1.04–4.02) 2.17*** (0.66–2.64) 1.92** (1.79–11.28) (1.26–5.51) (0.63–2.89) (1.14–4.14) (0.99–3.71) ® Reference category; level of significance *p < 0.10, **p < 0.05, ***p < 0.01; 95% confidence interval. MSDs, musculoskeletal disorders and related disabilities; the model additionally controls for age, schooling, working years, substance use, mental health, job satisfaction, BMI, wealth index and location of work; $, health condition Table 4 depicted the average exposure effect among exposed (AEEE) and highlighted the morbidities significantly found higher among waste collectors than the matched nonexposed group workers. For instance, morbidities such as injury/accident (34%), MSDs (23%), eye disease (19%), skin infection and disability (15% each) and respiratory disease (10%) found to be higher among waste collectors compared with the matched non-exposed workers (Table 4). Similarly, the finding suggested that the street sweepers significantly have higher morbidities than the matched non-exposed group workers. Mainly, the morbidities such as MSDs (18%), respiratory disease (17%), disability (16%), injury/accident (15%) and skin disease (12%) found significantly higher among street sweepers compared with the matched comparison group workers. The PSM matching method analysis suggests that the waste collecting and street sweeping occupation significantly increases the prevalence of major morbidities among exposed workers than the matched non-exposed workers. Table 5 demonstrated the treatment-seeking behaviour and health expenditure for major morbidities among exposed groups. For instance, 87% of comparison group workers seek medical care for injury and accident compared with the 85% of street sweepers and 61% of waste collectors in the past 6 months (Table 5). Similarly, all (100%) comparison group workers have sought medical treatment for the skin disease compared with the street sweepers (91%) and waste collectors (58%). A similar pattern is observed for respiratory disease, eye infections and MSDs among workers. For instance, 92% of comparison group workers seek treatment for eye infections compared with the 60% of street sweepers and 43% of waste collectors. Analysis of mean expenditure on morbidities depicted that workers working as street sweepers in MCGM spends significantly (p < 0.05) higher amount of money on the treatment for injury/accident followed by waste collectors compared with the comparison groups workers. For instance, street sweepers spend 5685 (± 6057.6) on the treatment of injury/accident followed by 4209 (± 4320.4) of waste collectors compared with comparison groups workers 3363 (± 2579.6), respectively (Table 5). Street sweepers suffering from respiratory and eye infections spend significantly Table 4 Average exposure effect (AEE) and average exposure effect among exposed (AEEE) of waste collecting and street sweeping occupation on major morbidities Major morbidities Waste collectors AEE Injury/accident @ Skin Respiratory Eye MSDs Disability Street sweepers AEEE AEE AEEE Coef. 95% conf. Coef. 95% conf. Coef. 95% conf. Coef. 95% conf. 0.33*** 0.15*** 0.04 0.15*** 0.19*** 0.09* (0.21 to 0.43) (0.07 to 0.24) (− 0.03 to 0.12) (0.07 to 0.24) (0.09 to 0.29) (− 0.00 to 0.19) 0.34*** 0.15*** 0.10*** 0.19*** 0.23*** 0.15*** (0.23 to 0.45) (0.09 to 0.21) (0.03 to 0.18) (0.12 to 0.27) (0.14 to 0.33) (0.05 to 0.24) 0.15*** 0.14*** 0.16*** − 0.01 0.18*** 0.18*** (0.06 to 0.23) (0.05 to 0.23) (0.07 to 0.25) (− 0.08 to 0.06) (0.09 to 0.28) (0.87 to 0.27) 0.15*** 0.12*** 0.17*** − 0.00 0.18*** 0.16*** (0.05 to 0.25) (0.06 to 19.55) (0.09 to 0.25) (− 0.07 to 0.06) (0.08 to 0.28) (0.07 to 0.25) Level of significance *p < 0.10, **p < 0.05, ***p < 0.01; Coef., coefficient, conf., confidence interval, MSDs, musculoskeletal disorders; @, health condition SN Compr. Clin. Med. Table 5 Treatment-seeking behaviour and mean expenditure (standard deviation) for major morbidities among study groups along with the results of ANOVA and post hoc (Tukey’s) tests Morbidities Injury/accident @ Skin Respiratory Eye MSDs Waste collectors Street sweepers Comparison group Waste collectors Street sweepers Comparison group p value for ANOVA Yes (N) Yes (N) Yes (N) Mean (SD) Mean (SD) Mean (SD) 61.5 57.6 62.5 43.2 61.8 78 33 32 44 89 84.8 91.2 82.7 60.0 84.3 46 34 52 25 83 86.7 100 93.3 92.0 90.2 15 12 30 25 61 4209 (4320.4) 2136 (1896.5) 2105 (1792.6) 1693 (2384.8) 4515 (6039.2)* 5685 (6057.6)* 2292 (1871.5) 4157 (3928.6) 2410 (1579.9)* 4392 (4761.1)* 3363 (2579.6) 1427 (1317.6) 3060 (2214.3) 1100 (568.2) 2298 (1757.5) < 0.05 0.40 < 0.05 < 0.05 < 0.05 N, number suffered from morbidity; @, health condition; MSDs, musculoskeletal disorders; SD (standard deviation); , mean rupees *Significantly different from comparison group workers (p < 0.05) higher amount of money on medical treatment followed by waste collectors compared with the comparison group workers. Considering the expenditure for MSDs, waste collectors and street sweepers significantly (p < 0.05) spend higher amount of money for the medical treatment compared with the comparison group workers. For instance, waste collectors suffering from MSDs spend 4515 (± 6039.2) on treatment followed by street sweepers 4392 (± 4716.1) compared with the comparison group 2298 (± 1757.5) in past 12 months. The results of Table 6 present the mean health expenditure for multiple morbidities among study groups. The finding of expenditure on multiple morbidities revealed that street sweepers suffered from any two major morbidities significantly (p < 0.05) spend higher money on the treatment followed by waste collectors compared with the comparison group workers (Table 6). For example, street sweepers spend 8500 (± 9647.8) on the treatment of any two diseases followed by waste collectors 7565 (± 8879.3) compared with the comparison group workers 4486 (± 3192.3). Similarly, for any three and above major morbidities, street sweepers significantly (p < 0.001) spend higher money 10,168 (± 7882.2) on the treatment followed by waste collectors 5821 (± 6744.4) compared with the comparison group workers 5560 (± 3579.3). Looking at the overall expenditure by additional one disease, the expenditure on the treatment among waste collectors and Table 6 Mean health expenditure for multiple major morbidities among study groups along with the results of ANOVA and post hoc (Tukey’s) tests street sweepers increases continuously compared with comparison group workers. Discussion The age and mean working years found to be more or less similar among all three workers’ groups. Majority of workers working as waste collectors and street sweepers were non-literate, and two-thirds of them belonged to the scheduled caste category. In India, waste collecting occupation or cleaning of public places is considered as poor people’s line of works traditionally. Scheduled caste people were socially and economically weakened and consistently restricted to inhuman practice of manual scavenging [32]. The manual scavenging has been prohibited by the law but at the same time people associated with cleaning work were not disengaged over the period. The lack of education, poor housing and insufficient diet affects their health rigorously. In addition, contextual vulnerability such as tobacco chewing, smoking and regular consumption of alcohol affects their immune system and resulted in further health deterioration. The prevalence of substance use was common among workers; for instance, 47% of waste collectors followed by 44% of street sweepers consume alcohol daily Multiple morbidities$ Waste collectors Mean (SD) Street sweepers Mean (SD) Comparison group Mean (SD) p value for ANOVA Any one Any two Any three and above 2400 (1861.2) 7565 (8879.3)* 5821 (6744.4) 3990 (4970.1) 8500 (9647.8)* 10,168 (7882.2)* 2655 (1854.8) 4486 (3192.3) 5560 (3579.3) 0.29 < 0.05 < 0.001 , rupees; SD (standard deviation); $, multiple response of major morbidities (injury/accident, skin, respiratory, eye, MSDs). *Significantly different from comparison group workers SN Compr. Clin. Med. compared with the comparison group workers (22%). Workers associated with waste collecting shows higher prevalence of injury/accident followed by street sweepers compared with the comparison groups workers. The waste collector’s direct exposure to the sharp and hazard waste materials resulted in injury/accident, skin disease and eye infections compared with comparison group workers. Particularly, the development of laceration due to sharp objects, fracture, rashes-itching, eye redness-watering, pain in upper back, lower back and hip/thigh found to be higher among waste collectors compared with the comparison group workers. Previous studies of workers associated municipal solid waste collection evidence the similar pattern of morbidities with compared to the general population [12, 13]. Likewise, workers associated with the street sweeping occupation reported higher prevalence of the skin disease, respiratory disease, MSDs and MSD-related disabilities compared with the comparison group workers [8, 27]. Particularly, street sweepers suffered with skin itching, dermatitis, episodes of asthma, chronic cough, breathlessness, watering-itching eye, pain in the shoulder, upper back, low back and wrist/hand compared with the comparison group workers. The previous study validated our findings and evidence that the prevalence of all respiratory disease found to be comparatively high among MSW workers than in control group; particularly the shortness of breath was the major respiratory problem among municipal workers [2, 3, 10, 17]. The PSM method highlighted that the occupation of street sweeping and waste collecting significantly raised the prevalence of injury/accident, skin disease, respiratory disease, MSDs and related disabilities among exposed group workers compared with the matched non-exposed group workers. The physical body posture and workload during the working hours might be the major risk factor for developing MSDs among street sweepers and waste collectors as suggested by previous studies [11, 23]. Waste collectors and street sweepers bear higher burden of OOPE due to multiple illnesses compared with comparison group workers. Waste collectors significantly incurred higher burdern of expenditure followed by street sweepers compared with the comparison group workers. Similarly, workers having any three and above major morbidities spend significantly higher amount of money on treatment compared with those who have any one disease. In the larger context, medical and industrial waste is not segregated from domestic waste which makes waste collectors and street sweepers vulnerable to a wide array of health risks. Workers suffered from health hazards due to the contents of materials they handle, emissions from waste materials and the inadequate used of protective measures. The work condition and workplace make them vulnerable to development of multiple communicable and non-communicable diseases. Health deteriorates continuously after the retirement which leads to long-term disability and causes premature death. For instance, past studies suggested that the majority of workers associated with solid waste collection die because of communicable diseases and mainly due to the tuberculosis before the completion of 58 years of age [31]. The majority of workers spend higher proportion of their mean expenditure on medicine items followed by doctor fees, medical tests and transport facilities. And the households’ savings followed by the money borrowed from friends and relatives were mainly used as the major source of medical expenditure. Although workers are formal employees of MCGM, but the reimbursement of health expenditure through insurance policy was observed negligible for all the three types of workers. However, the study has estimated the prevalence of different morbidities/health conditions among waste collectors and street sweepers but at the same time we acknowledge the limitations of the study. We have used the self-reported morbidities which are subject to the recall bias, may cause the inflated risk estimates and sometimes faced difficulties in demonstrating the cause-effect relationships. Policy Implications The study deals with the policy implication based on the results and suggests immediate possible actions with the following recommendations. The MCGM may adopt the job rotation system between waste collectors and street sweepers to reduce the workload and the risk of developing morbidities. Workers working in the high slum concentration areas may be shifted to low slum concentration areas since the workload varies by place of work. The burden of morbidities may be reduced by taking the preventing measures and providing proper medical care at an early stage. Considering the municipal worker’s occupation, the preventive measures mainly includes the use of protective gears/safety tools during working hours and the adaptation of personal hygiene practices. The MCGM have a provision of regular medical check-up in civil health facility for workers, but we observed poor implication of the policy. Therefore, we suggest to regulate the medical check-up with provision for private health facility. The MCGM need to mechanized the SWM department particularly sewer and community dustbins which need manual handling; this may reduce the direct exposure of workers to the filthy waste. To reduce the burden of medical expenditure corporation may introduce the family health insurance facility for workers. Compliance with Ethical Standards Conflict of Interest The author declared no conflict of interest. Ethical Approval This paper is a part of the PhD thesis work conducted during 2013–2018 in IIPS. 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