The patients arrive every day in Chinese hospitals with disabling and fatal diseases, acquired while making products for America.
On the sixth floor of the Guangzhou Occupational Disease and Prevention Hospital, Wei Chaihua, 44, sits on his iron-rail bed, tethered to an oxygen tank. He is dying of the lung disease silicosis, a result of making Char-Broil gas stoves sold throughout the U.S.
Down the hall, He Yuyun, 36, who for years brushed America's furniture with paint containing benzene and other solvents, receives treatment for myelodysplastic anemia, a precursor to leukemia.
In another room rests Xiang Zhiqing, 39, her hair falling out and her kidneys beginning to fail from prolonged exposure to cadmium that she placed in batteries sent to the U.S.
"Do people in your country handle cadmium while they make batteries?" Xiang asks. "Do they also die from this?'
With each new report of lead detected on a made-in-China toy, Americans express outrage: These toys could poison children. But Chinese workers making the toys -- and countless other products for America -- touch and inhale carcinogenic materials every day, all day long: Benzene. Lead. Cadmium. Toluene. Nickel. Mercury.
Many are dying. They have fatal occupational diseases.
Mostly they are young, in their 20s and 30s and 40s. But they are dying slow, difficult deaths, caused by the hazardous substances they use to make products for the world -- and for America. Some say these workers are paying the real price for America's cheap goods from China.
"In terms of responsibility to Chinese society, this is a big problem for Americans," said Zhou Litai, a lawyer from the city of Chongqing who has represented tens of thousands of dying workers in Chinese courts.
The toxins and hazards exist in virtually every industry, including furniture, shoes, car parts, electronic items, jewelry, clothes, toys and batteries, interviews with workers confirm. The interviews were corroborated by legal documents, medical journal articles, medical records, import documents and official Chinese reports.
And although these products are being made for America, most Chinese workers lack the health protections that for nearly half a century have protected U.S. workers, such as correct protective masks, booths that limit the spread of sprayed chemicals, proper ventilation systems and enforcement to ensure that their exposure to toxins will be limited to permissible doses measured in micrograms or milligrams.
Chinese workers also routinely lose fingers or arms while making American furniture, appliances and other metal goods. Their machines are too old to function properly or they lack safety guards required in the U.S.
In most cases, U.S. companies do not own these factories. American and multinational companies pay the factories to make products for America. From tiny boutiques to multinational corporations such as Reebok and IKEA, companies compete in the global marketplace by reducing costs -- and that usually means outsourcing manufacturing to China. Last year, the U.S. imported $287.8 billion in goods from China, up from $51.5 billion a decade ago, according to the U.S. Commerce Department. Those imports are expected only to increase.
Worker health and safety are considered basic human rights. But in the global economy, responsibility to workers often gets lost amid vast distances and international boundaries.
"This is a big-picture problem," said Garrett Brown, an industrial hygienist from California who has inspected Chinese factories that export to America. "Big-picture problems don't have quick or easy solutions."
The International Labor Organization publishes international standards for workplaces. China agreed to many of those standards and also enacted a 2002 law setting its own rigorous standards. Under Chinese law, workers have the legal right to remain safe from fatal diseases and amputations at work.
But the law has not been enforced, Chinese and international experts agree. Economic growth has been a more important goal to China than worker safety.
Even the World Trade Organization, which maintains some barriers to trade to protect consumers' health, does not concern itself with issues of workers' health. As a result, enforcement of health and safety standards has been left to the governments of developing countries and the companies that outsource to those countries.
Often, smaller companies never even visit the factories where their products are made. Larger companies try with only limited success to audit operations, often complaining that their efforts are failing. Records are falsified and unsafe machines are used after audits. Safety guards are removed so workers can produce faster.
"Through auditing tours, we can make good improvements and changes, but those changes are not sustainable," complained Wang Lin, a manager for IKEA based in Shanghai. "Chinese government law enforcement is greatly needed," added Wang. "Without that, companies cannot sustain a good compliance program."
The Chinese Ministry of Health in 2005 noted at least 200 million of China's labor force of 700 million workers were routinely exposed to toxic chemicals and life-threatening diseases in factories. "More than 16 million enterprises in China have been subjecting workers to high, poisonous levels of toxic chemicals," the ministry said at a conference on occupational diseases in Beijing, which was reported by the state-controlled media. The ministry particularly blamed "foreign-funded" enterprises that exported goods.
China has more deaths per capita from work-related illnesses each year than any other country, according to the ILO. In 2005, the most recent year for which data are available, 386,645 Chinese workers died of occupational illnesses, according to Chinese government data compiled by the ILO and cited in the July 14, 2006, Journal of Epidemiology. Millions more live with fatal diseases caused by factory work, other epidemiologists estimated in the article.
The number of workers living with fatal diseases does not include those who suffer amputations. Primitive, unsafe machines with blades that lack safety guards have caused millions of limb amputations since 1995, according to lawyers for Chinese workers.
The scale of the fatal diseases, deaths and amputations challenge the common wisdom -- recited in both the Chinese and American press -- that U.S. trade with China has helped Chinese factory workers improve their lives and living standards. "If I had known about the serious effects of the chemicals, I would not possibly have taken that job," said Chen Honghuan, 40, who was poisoned while handling cadmium to make batteries for export to Rayovac, EverReady, Energizer and Panasonic in the U.S.
China's 2002 Occupational Disease and Prevention Control Act established limits on workplace poisons, which in most cases are as strict or nearly as strict as U.S. regulations.
But Chinese and foreign experts agree enforcement has been lax. After the law was enacted, for example, the average benzene level in Chinese factories reported in 24 scientific journals from 2002 through 2004 was more than 11 times the allowable level, according to scientists from Fudan University of Public Health in Shanghai, writing in the November 2006 Journal of Regulatory Toxicology and Pharmacology.
Scientists reached the same conclusion about workers' exposure to lead in the manufacture of paint, batteries, iron and steel, glass, cables and certain plastics.
"The data demonstrated that many facilities in the lead industries reported in the literature were not in compliance with the OELs (occupational exposure limits), wrote Xibiao Ye and Otto Wong in a 2006 medical journal article. "Similarly, there appeared to be only a minor impact of the 2002 Act on the reduction of occupational lead poisoning in China. The current overall occupational health-monitoring system appears inadequate, lacking the necessary enforcement."
Most American businesses that import from China are small and medium-sized, U.S. shipping records show. Unlike large companies, they ordinarily do not visit the factories or check on factory conditions.
"I found the factory on the Internet two years ago," Michael Been, owner of A to Z Mining Tools in St. George, Utah, said of a factory he uses in Guizhou Province. "They have someone who writes English."
Been has never been to the factory and has no plans to visit.
Some larger companies, however, pay auditors to monitor conditions in the factories they use. But auditors' visits provide merely a "snapshot in time," business owners say. Chinese workers suggest those snapshots often are staged, with the number of toxins reduced before the visits and workers reassigned to new and safer tasks. The glimpse that visitors get of Chinese factories often is incomplete for other reasons: Many large factories have small satellite "workshops," which are much smaller factories nearby that visitors never see, according to Chinese workers interviewed for this story.
"These Americans visited the large factory, but never visited the workshop where I worked," Chen Faju, 31, said as she pointed to numerous photos of visiting Americans in her factory's magazines. "If they had visited, they would have smelled the poisons."
Chen and colleagues from the workshop were hospitalized for chronic anemia and myelodysplastic anemia, beginning in 2002, a result of brushing toxic glues for years onto the soles of New Balance and other sport shoes sold in the U.S. The shoes were made by 30,000 workers in the Yue Yuen industrial park in the city of Dongguan.
Chen's medical record, dated Feb. 14, 2007, advises that she be removed from a job of "working with organic chemicals." A manager from Chen's workshop, Du Masheng, said toxins are not used anymore.
In addition, auditors typically have been more concerned with fair wages than worker safety.
Derek Wang, a former auditor for Reebok, recalls that he and his former boss lurked outside factories at night to see if workers were working overtime so they could make sure they were paid for the additional work.
But asked for the ingredients of glues the factories used to make the shoes, Huang said he did not know. He never had glues tested for carcinogenic benzene or n-hexane.
Chinese provincial governments are responsible for checking compliance with Chinese law. But too often, officials have a financial stake in businesses, leading to corruption and 24-hour warnings before rare inspections occur, said Liu Kaiming, executive director of the Institute of Contemporary Observation, a Chinese think tank.
There are too few inspectors in China to monitor safety, experts say. There is one inspector for every 35,000 Chinese workers, Brown, the American industrial hygienist, calculated in a journal article. Local governments in China also do not fully understand the "adverse effects on workers' health" of occupational hazards, according to an article this year in the journal Regulatory Toxicology and Pharmacology.
"Chinese labor law is not that bad," said Dominique Muller, the Hong Kong director of the International Confederation of Free Trade Unions. "The problem is the implementation."
Added Guo Jianmei, a law professor at Beijing University who represents workers injured in factories: "The problem is that the Chinese government does not have an incentive to reform the enterprises."
In most countries, trade unions help ensure that employers abide by occupational health and safety regulations. The unions also help train workers in proper use of machines and protective equipment.
China has only one trade union, controlled by the central government. Its function is to enhance production and maintain labor discipline. Workers who try to organize or establish their own free trade unions are arrested and face lengthy prison sentences. Lawyers who have tried to help them also have been imprisoned.
"In China, there is absolutely nothing you can do," said Au Loong-yu, a researcher for the nonprofit organization Globalization Monitor in Hong Kong. "Workers have been robbed of the basic tool of self-defense: forming independent unions. And the government is biased in favor of the business sector, so it cracks down on workers who try to speak up for themselves."
Indeed, the Chinese government treats issues related to workers' rights as sensitive matters of state security. Even those workers with diseases or amputations who try to help other workers with similar conditions -- by forming independent NGOs (non-government organizations) -- have had their organizations shut down by state security police, they said in interviews.
"Now we pose as a business, as a consulting firm," said Zhu Qiang, an underground NGO leader in Shenzhen who lost his arm in a crude machine while making plastic bags for America.
China's failure to permit free trade unions translates into additional cost savings for American consumers and profits for American companies, reducing the cost of manufactured imports from China from 11 percent to 44 percent, according to Columbia University law professor Mark Barenberg.
The lack of unions also makes it even more lucrative to use Chinese workers to make goods.
"In the U.S., if you are a manufacturer, you have to contribute to unemployment insurance and worker compensation insurance, you have to buy workplace environmental insurance and liability insurance, and you have to comply with the occupational health and safety law," said David Welker, research coordinator for the International Brotherhood of Teamsters in Washington, D.C.
U.S. businesses, while adamant they don't want Chinese workers to get sick or hurt, know their costs are lower because the regulatory environment is more lax.
Meanwhile, the shipping containers from China arrive every day.
This article by Loretta Tofani, a Pulitzer Prize-winning reporter, was funded by grants from the Pulitzer Center on Crisis Reporting in Washington, D.C., and the Dick Goldensohn Fund for International Reporting at The Center for Investigative Reporting in Berkeley, Calif.. It appeared earlier in 2007 in the Salt Lake Tribune. Read the complete six-part series.