Karoshi: Is Working Long Hours Worth the Health Risks?

In 1969, a 29-year-old man working in the shipping department of Japan’s largest newspaper died suddenly of a stroke. While at first his case was called occupational sudden death, it was later determined that his stroke was caused by shift work and an increased workload. His was the first documented case of what became known in Japan as karoshi—literally translated, “death from overwork.”

More cases of karoshi were reported during the 1970s. Due to pressure from wives and colleagues of karoshi victims, doctors began to investigate how these deaths were related to work. Most of the victims were shift workers, drivers, newspaper and television workers, construction workers, and salesmen who worked long hours (on average 60 hours per week), night shifts, and irregular schedules.

As public concern increased, Japan’s Ministry of Labor began publishing statistics on karoshi in 1987. Compensation for karoshi deaths peaked in 2002 and has leveled out since then. But compensated cases only tell a small piece of the story—death by overwork can be a difficult thing to prove, so many cases are uncompensated.

Karoshi victims are most often otherwise healthy men with no evidence of disease. They might feel symptoms including headache, dizziness, nausea, and stomachache during the 24 hours leading up to their stroke or heart attack. Karoshi is known as a silent killer; an array of stress-induced physiological changes develop over time, quietly doing damage under the surface, and then suddenly cause a fatal cerebrovascular or cardiovascular event.

While the rate of karoshi due to heart attack and stroke may be leveling off in Japan, the rate of karoshi due to mental disorders continues to climb. Overwork doesn’t just mean physical burnout, strain, and fatigue; it often includes psychological stressors like unrealistic expectations and challenging working relationships with bosses and co-workers. And it can happen at any age. More than half of Japanese workers receiving compensation for mental disorders are in their 30s or younger, and 47% of compensated mental disorders were related to factors other than long working hours.

In 2019, 1949 people in Japan committed suicide due to problems at work. Suicide related to overwork is so common that they have a name for it too: karojisatsu.

Japanese culture has long romanticized overwork and held those with a strong work ethic in high esteem. In many companies, there is a great deal of peer pressure to conform to these ideals. People work long days and take only about half of their paid vacation time because their bosses and co-workers are doing the same. And in general, Japanese companies do not offer paid sick leave—workers must use vacation time if they get sick.

Things are slowly changing, due in part to pressure from the younger generation of workers ages 18-34, who feel vacation-deprived and report increasing rates of mental disorders due to overwork. In 2014, the Japanese government passed the “Act on Promotion of Preventive Measures against Karoshi and Other Overwork-Related Health Disorders,” a nationwide initiative toward the prevention of overwork-related disorders and death. The government has set a goal of increasing the rate of taken annual paid leave to 70% in 2020.

Meanwhile, there is a grassroots movement encouraging workers to take their paid vacation time.
In November 2019 in Osaka, a Buddhist priest led a large ceremony called Yukyu Joka, or “paid holiday purification.” Three hundred lanterns printed with messages of regret about unused paid holidays represented the spirit of missed time off. The messages included a mother who had to postpone her daughter’s nursery school birthday for seven months, a man who missed the birth of his first child, the end of a friendship, and missed funerals—all because work was more important.

Karoshi in the United States

Recently, Japan’s Ministry of Health, Labor and Welfare defined karoshi as “sudden death of any employee who works an average of 65 hours per week or more for more than 4 weeks or on average of 60 hours or more per week for more than 8 weeks.”

My reaction to that was—really? Sixty to 65 hours per week doesn’t sound like that much. As an American, I can easily think of a handful of people I know who work five 12-hour days on a regular basis, plus some catch-up work at home on the weekends.

In fact, the US surpassed Japan in average number of hours worked in the mid 1990s. Americans now work 10.7% more hours, or 4.5 more weeks per year, than they did 40 years ago. And like the Japanese, 55% of Americans don’t use all of their paid vacation time.

Unfortunately, the US government and health care system doesn’t recognize or track the effects of overwork as a specific condition. Like the Japanese, Americans value hard work. Our Protestant work ethic and the capitalist economy it contributed to have created a society in which we must continue to work harder and harder in order to succeed—or in some cases, just barely get by. Income inequality in the US has become extreme, with 1 in 8 Americans living below the poverty line while the incomes of the wealthiest 5% of Americans grow faster than those of everyone else. For many people, the only way to pay the bills or work toward a better life is to work more hours.

The health risks of overwork

The negative health effects of working long hours often take time to surface. Adrenaline may keep you going for a while, but in time, working 10- to 12-hour days will likely lead to some sort of chronic health condition like cardiovascular disease, diabetes, depression, anxiety, chronic stress and fatigue, or substance abuse.

Researchers in China, another country where karoshi is a public health concern, have shown how overwork in rats leads to malignant cardiac arrhythmia—heartbeat that is irregular, too fast, or too slow, leading to chest pain, dizziness, stroke, and death. And a Japanese study of 260 men ages 40-79 found that those working more than 60 hours per week were twice as likely to suffer a heart attack, and those who frequently got less than five hours of sleep per night were two to three times more likely to suffer a heart attack.

When people work long hours on a regular basis, they tend to adopt unhealthy lifestyle habits, like skipping meals, eating fast food, smoking, drinking alcohol, using caffeine or other stimulants excessively, and not exercising. Weight gain and obesity are associated with long working hours due to poor diet, being sedentary at work, and not having time to exercise. And lack of exercise combined with either being sedentary or doing repetitive physical activities at work leads to increased rates of chronic musculoskeletal pain.

Working long hours affects our psychological health too. Employees who work more than 55 hours per week have a 66% increased risk of depression and 74% increased risk of anxiety compared to those who work 35-40 hours per week. People who work more than just 40 hours per week are four times more likely to have moderate to severe suicidal thoughts. Working long hours also increases risk of insomnia, which is often caused by psychological stress.

And if you feel guilty about taking a vacation, it’s time to get over it. Taking vacations not only makes you a happier and more productive worker, but it can add years to your life. Researchers found that taking vacation time every year reduced overall risk of death by 17%, and risk of death from heart disease by 32%. And the Framingham Heart Study, ongoing since 1948, found that women who took the least vacation time were nearly eight times more likely to have a heart attack than those who took at least two vacations per year.

Does a shorter workday work?

If you need any more motivation to ease up on your work schedule, take into consideration that your productivity declines the more hours you work. A Stanford University study found that productivity declines sharply when people work more than 50 hours per week. Productivity drops so much above 55 hours per week that working any more hours is pointless; people who work up to 70 hours get the same amount of work done as those who work 55 hours. And an interesting Boston University study found that some men fake working 80-hour work weeks while only working 50-60 hours, and their employers can’t tell the difference between their output and that of employees who actually work 80 hours per week.

Some countries are paying attention to this research and experimenting with shorter workdays in order to increase productivity, happiness, and well-being of their citizens. Sweden shifted nurses at a government-run retirement home from eight-hour workdays to six-hour workdays for 23 months, with positive results: the nurses used less sick leave, reported better health and increased energy, exercised more, and were more productive at work. Unfortunately, the shortened workday is not likely to become mainstream anytime soon in nursing or similar professions that require an employee to be on duty, because it results in increased short-term costs (due to additional staffing) to the company or government.

However, it’s more realistic that employees whose work is based solely on productivity may see their workday shortened in the near(er) future. Companies in Sweden and around the world are experimenting with shorter workdays and four-day workweeks. Employees at Toyota service centers in Gothenburg, Sweden have been working six-hour shifts for more than 15 years, and the centers report happier staff, lower turnover, and increased profits during that time. Swedish digital marketing company Brath reports that their six-hour workdays have increased productivity as well. Stockholm-based app developer Filimundus also adheres to a six-hour workday; to make it work, they minimize meetings and ask staff to stay away from social media and personal distractions. ICE Group in Ireland has instituted similar practices, making meeting times more structured and asking employees to stay off social media and not interrupt other employees while they’re working.

Andrew Barnes, founder and owner of financial estates manager Perpetual Guardian, found a successful way to roll out the shortened workweek to his staff. He gave them the opportunity to reduce their work time by 20% as long as they maintained their current productivity, and it was the employees’ responsibility to tell him how they were going to do it. While a shorter workweek reliably leads to improved well-being, Barnes says that when you’re running a company, that can’t be the focus—employees must know that work hours are being shortened in order to boost productivity. Barnes is so passionate about a shortened workweek that he wrote a book called The 4 Day Week.

In August 2019, Microsoft Japan tried out a four-day workweek, giving employees a paid day off every Friday. The results were dramatic: productivity increased by 40% compared to the previous August, while electricity costs fell by 23%.

Shortened workweeks are gradually becoming more commonplace in the United States. One third of organizations now offer “compressed” workweeks of four 10-hour days, while four-day, 32-hour workweeks are offered by 15% of organizations.

This trend is likely to continue, as 70% of US workers feel that the 40-hour, five-day workweek is outdated. And 45% of US workers feel that they could get their work done in less than five hours if they were able to work uninterrupted; this could encourage the trend toward working at home.

How do you want to work?

Even before the COVID-19 outbreak forced many people to start working from home, 27% of US companies offered full-time telecommuting, 42% offered it part-time, and 69% offered it as needed. Now, as some employees get used to working from home for the first time, and their employers appreciate the benefits of reduced rent, utilities, and other expenses, it’s likely that telecommuting will become even more common.

For essential workers, a dramatic shift has occurred in the opposite direction: they’re working more hours on-location, and likely experiencing increased stress due to the risk of infection. The work these people do is greatly needed and can be fulfilling, but sadly it takes a toll on their physical and mental health. These are the folks who should be first in line to work shorter shifts for equal pay so that they can be optimally productive while on duty and still have time to take care of themselves. Unfortunately, for most essential workers this isn’t the case right now. To be an essential worker is a sacrifice that shouldn’t be taken lightly.

Our new normal is likely to last a while, and it’s a good time to evaluate the work you do and how you do it. The pandemic has likely affected your work schedule and/or location in some way, and given you perspective on your previous work/life balance. Consider these questions:

Are you happy with the type of work you’re doing?

Is your work having any negative effects on your health?

Would working fewer hours allow you to enjoy your work more, and/or improve your health?

If given the choice, would you prefer to work five 6-hour days or four 8-hour days?

If you could work shorter workdays or a shorter workweek, what would you do in your new free time?

What do you miss about your pre-pandemic work?

Visualize your ideal work/life balance: the number of hours you work per day and days per week, where you do your work, and what type of work you do. Is this ideal possible? How can you make it happen?