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The Amazon fulfillment facility in Eastvale, California, was gearing up for its annual onslaught of holiday orders in October 2016 when Andrea appeared for her first day of work. A creative child from a working-class Latino family, Andrea dreamed of becoming an English teacher. With her job at Amazon, she hoped she could work and pursue an education at the same time. For years, the 27-year-old English major had taken other short-term warehouse jobs—mostly for retail companies, including the shoe store Zumiez. The work ranged from tagging items to entering UPC codes for returned packages. It was mundane, but it was a good way to make money while she finished her degree. Andrea assumed Amazon would be similar, albeit more strenuous.

More than two years later, injuries to her shoulder, neck, and wrist sustained during her time at Amazon—lifting up to 100 items an hour, moving them to conveyor belts, and then hauling them into trailers—have made it nearly impossible for her to type without the aid of voice dictation software. She has surges of pain up her spine and hip. She can’t write for too long without her right wrist flaring up. Even if working a new job was physically possible, scheduling it around class and her new regular rotation of doctor’s appointments would be difficult. She sees a chiropractor, acupuncturist, and primary care physician for multiple appointments a week. Only the primary care doctor is covered by Medi-Cal, the state version of Medicaid that she now relies on for health insurance. (Andrea has asked Mother Jones not to use her last name in order to protect her future work opportunities. Her employment at Amazon was verified by the company.)

Andrea is one of Amazon’s more than 125,000 workers who work in vast facilities that can span the length of over 20 football fields. Attracted by promises of steady bonuses and health insurance, many workers like Andrea have discovered an unofficial culture prioritizing speedy distribution of merchandise over the health and well-being of employees—sometimes with disastrous results. In locations from Los Angeles to Baltimore, Amazon employees face potentially unsafe working conditions that have been well documented in the media and by government agencies.

According to inspection data by the Occupational Safety and Health Administration (OSHA), the government agency charged with overseeing worker safety, there have been over 100 federal investigations launched against Amazon since 2016. OSHA has also issued letters to Amazon advising the company to voluntarily change conditions that posed hazards to employees. In 2015, OSHA issued a warning letter specifically about the use of EMTs in Amazon’s AmCare clinics in a New Jersey warehouse. The same facility is currently undergoing a follow-up inspection.

“It kind of reminds me of an American-made sweatshop,” Andrea says, reflecting on how she feels about her experience working for Amazon. “It’s cleaner and nice. You get praised if you meet your numbers. But you get humiliated if you don’t.” The only injuries Amazon ever seemed to take seriously, she says, involved blood. The main concern, it seemed, was not getting stains on the merchandise.

Amazon points out that the federal government has requirements requiring special control plans to deal with exposure to bodily fluids, including blood, to prevent the potential spread of infectious disease. The company disputed the characterization that its working conditions are comparable to a sweatshop. “We disagree. We’re proud of the quality work environment provided to associates in our fulfillment centers,” Amazon spokeswoman Ashley Robinson said in an email to Mother Jones. “The facilities are temperature controlled, they are well-lit, employees receive competitive wages and comprehensive benefits, and everyone is encouraged to be a leader on behalf of the customer and the company.”

AmCare clinics, run by licensed emergency medical technicians, are meant to provide employees with onsite first aid in a job that, even with the most stringent safety precautions, can be strenuous and result in accidents. But Andrea’s story, along with over a dozen other cases from interviews with Amazon workers, court records, and OSHA logs, show that hazards on the warehouse floor can launch months and years of medical injury that ultimately result in worker disability. Between 2015 and 2018, OSHA reported 41 “severe” injuries resulting in hospitalization, including six amputations and 15 fractures, associated with Amazon delivery or fulfillment jobs. This data does not include state OSHA records, and Amazon declined to make its internal safety data available to Mother Jones. While several Amazon employees who spoke with Mother Jones, including three in an interview facilitated by Amazon’s PR team, said injuries were not common at their facilities and they enjoyed working for the company, for the dozens of workers injured at Amazon each year the job can have a radically different outcome.

“There’s this sense that people should be able to get what they want immediately,” says Marcy Goldstein-Gelb, co-executive director of the watchdog nonprofit National Center for Occupational Safety and Health, tells Mother Jones. “But not at the expense of having your workers be disposable. Their bodies and lives aren’t disposable.”

Andrea was raised in Fontana, a former steel mill town about an hour east of Los Angeles, a region that is now dominated by the trucking industry and warehouse jobs. With 15 warehouses, Southern California is Amazon’s densest region of fulfillment centers. The Eastvale warehouse where Andrea worked was on the larger side at 1 million square feet. Nonetheless, Andrea says, “if you weren’t feeding the trailers on time, the boxes would spill over and then people would be tripping on them.” This is all part of the chaotic mix of human beings and robots that sort and distribute millions of items. During the height of the holiday rush last December, 24 workers were hospitalized after a can of bear spray was punctured in a New Jersey warehouse. Both OSHA and Amazon tell Mother Jones they are still investigating the incident.

“It kind of reminds me of an American-made sweatshop. It’s cleaner and nice. You get praised if you meet your numbers. But you get humiliated if you don’t.”

With the exception of managers, human resources, and AmCare jobs, most of the positions at Amazons’ warehouses revolve around merchandise. Items are stowed in randomized pods across the warehouse, from which pickers will pluck the products. From there, they’ll be sent to a packing line where items are packed and then labeled for shipping before being loaded into a trailer and shipped by delivery contractors.

Pickers like Andrea are tasked with pulling tightly packed items from the warehouse’s looming shelves and filling pallets that are sent down a conveyor line to be packed and labeled. As outlined in an OSHA report, to meet production goals often topping 100 items an hour, workers strain to lift, pull, and grip items that weigh up to 29 pounds.

Andrea started out as a packer, putting items into boxes and getting them ready for shipment. But her performance impressed supervisors, and in December, at the peak of the holiday season, they moved her to picking. She worked grueling 10- and 12-hour shifts, both days and nights. The pace of the work quickly caught up to her. One morning in January 2017, Andrea woke up with her right hand bent into a claw-like shape. She used her left hand to pry her fingers straight, but even opening her bedroom door sent a shock of pain from her palm up through her shoulder. At the warehouse, coworkers told her to shrug off the soreness and that it was “normal.” But the sharp pain persisted. Andrea said she had to keep herself from crying as she tried to pick up items from the tightly packed cubbies. When she told a supervisor that day, he told her to go to AmCare. The workers there gave her an icepack but otherwise didn’t tell her to report her injury. After she secured the icepack to her hand with a rubber band, Andrea went back to climbing up a ladder to reach items up on the shelves. Navigating the ladder with one hand encumbered by the icepack proved too difficult, and she fell three more times that day. She says that after complaining to her manager about the hazard five times, she stopped using the icepack. (Amazon says that according to its records, Andrea stated that she was able to return to work.)

On January 31, as she was working the night shift and unloading boxes, the pain in her wrists became unbearable. The next day, she saw a doctor, through her parents’ insurance, who put her on state disability for her wrist and hand pain. Her doctor asked why she didn’t report the injury directly to Amazon, but she said no one there would listen to her.

When she returned to work five weeks later, unable to afford to remain on state disability, her manager demanded to know why she hadn’t reported the injury to Amazon before seeking outside medical care. “He goes, ‘You screwed the pooch on this one.’ Why didn’t you report it?’” Andrea recalls. He immediately put her back on the picking line.

Onsite clinics like AmCare aren’t uncommon for large facilities like Amazon’s warehouses. In 2014, a National Association of Worksite Health Center study found that 43 percent of surveyed companies had an onsite or near-site clinic in place. In 2009, Amazon introduced its own AmCare clinics, which are staffed by licensed EMTs, and has even hinted at franchising in-house medical clinics for the white-collar workforce using data-driven optimization.

But for its blue-collar workers, the AmCare model has been a far cry from a user experience worth reproducing. Described as having the atmosphere of a cramped school nurse’s office by Amazon employees, the clinic’s function, according to the company’s website, is to “provide first aid care to injured employees, actively analyze tasks for potential safety issues, [and] participate in the Worker’s Compensation process.”

“There’s this sense that people should be able to get what they want immediately. But not at the expense of having your workers be disposable. Their bodies and lives aren’t disposable.”

Alongside site safety managers, AmCare workers are tasked with preventing and documenting workplace injuries and serving as decision makers for whether an employee should receive professional medical care. Workers tell Mother Jones they are not allowed to carry cellphones onto fulfillment center floors, making it impossible for them to call 911 themselves.

In order to access AmCare treatment, a worker must first report their injury to a manager. At that point, they have to take time off the clock to see the onsite medical specialist. From there, the EMTs staffing the clinics have enormous discretion in deciding if an employee should be sent to a doctor or if their treatment is kept in-house for anywhere up to 21 days, at which point Amazon policy requires AmCare to refer the worker to outside treatment. Because they don’t have licensed physicians onsite at warehouses, AmCare treatments are meant for temporary relief—solutions such as aspirin or bio-freeze pain reliever spray. According to an Amazon spokesperson, company policy is that there is no limit to the number of times an Amazon associate can go to AmCare. Once a worker has been referred to an outside doctor, AmCare is prohibited from offering any further treatment for a specific injury unless that doctor wrote a formal treatment plan.

But some employees accused Amazon of prioritizing productivity over the safety features in the company policy. A former safety manager, who worked with AmCare employees and traveled to other warehouses in the New England area to train safety personnel, told Mother Jones that AmCare was not the root of the problem at Amazon; the pace of production was. “If you had an injury…there was no leniency, you were expected to keep that rate,” he says. “It was utterly ridiculous.” (Amazon disputed these claims, telling Mother Jones in an email that there is no set production quota for workers.)

Navigating these concerns can be difficult for regulators. OSHA can issue citations against companies that fail to make timely medical referrals for workplace injuries, though it has only done so once in the agency’s nearly 50-year history. More often, the onus falls on state agencies. In 2017, in reaction to increased OSHA scrutiny of the meat and poultry processing industry, a report to Congress by the United States Government Accountability Office outlined concerns that inspectors were limited to contacting state authorities over facilities that medical staff were improperly certified or supervised.

According to former OSHA officials, that kind of scrutiny is less often cast on the warehouse industry. As for the unsafe conditions cited by many employees, it’s rare that an OSHA inspector will ever witness them. There are only 2,100 OSHA inspectors for over 8 million worksites, and OSHA enforcement activities have declined under President Trump.

Meris Whitacre’s medical problems started and ended with AmCare. The 22-year-old former Amazon employee in Raleigh, North Carolina, worked in a processing line where she scanned items for missing destinations. Ten hours a day, she twisted her body to move boxes, which she said were often labeled with the wrong weights, into pallets that were often too small for the packages. When she went to AmCare for back pain, she was told she would need to see a physician approved by the company’s workers’ compensation insurance for the injury. Neither HR nor her manager seemed to know what paperwork she needed exactly. But she persisted and was eventually able to see an outside doctor.

Whitacre was told by an insurer-approved doctor that she had a herniated disc and an annular tear, and she took two months of disability leave. But when she was cleared to go back to work, her manager would only allow her to continue to work on the production line, and her pain quickly returned. She again went to AmCare, but after several visits they told her to stop coming, saying the pain was due to scoliosis, a pre-existing condition. (When asked about Whitacre’s case, an Amazon spokesperson said there is no limitation on the number of times an employee is allowed to visit AmCare.)

After returning to her doctor, Whitacre was finally able to get work restrictions to keep her off the scanning line. But management told her they couldn’t accommodate the order. They shortly fired her for taking too many unearned hours of time off and for “disciplinary issues.”

“Instead of applying for workers comp when they know you hurt your back, they want you to go to AmCare,” Whitacre says. “I just don’t understand why a company that makes over a trillion dollars can’t pay workers comp.”

One reason is lawmakers. Since the early 2000s, most states have drastically gutted their worker compensation laws, making it more difficult to qualify for benefits. In at least 37 states, employers (or their insurers) exert additional control by having say over which doctors an injured worker can see. A 2015 OSHA report found that only 21 percent of the total medical and related costs to workers by workplace injury is covered by workers compensation. The same study found that for companies that rely on third-party staffing agencies, the chances of a payout are even lower. With less safety training, the chance of injury is also higher. Mother Jones interviewed both full-time (like Andrea) and contract warehouse workers. According to Amazon, 90 percent of its warehouse workers are full-time Amazon employees.

“Any host employer using temporary workers has the responsibly to ensure those workers have the same level of full safety protections as the host employers,” said David Michaels, assistant secretary of labor during the Obama administration and one of the report’s authors. “That can be a challenge but it’s imperative that they do that.”

“I was battered and bruised at Amazon, and they didn’t care,” D’Anna Smith, 42, tells Mother Jones. It was Amazon’s peak season when Smith started working at a warehouse in Schertz, Texas. Smith says that during safety training, the company emphasized that workers should report their injuries and go to AmCare if they felt they were in pain.

The problem was, there were few workers who were not in pain. Smith drove forklifts and moved large items, the size of which mandated two employees be involved. While she admits that the transition into warehouse work after a lifetime of being a self-described desk jockey at call centers was difficult, it seemed as if once she started working there, other employees were “dropping like flies.” But like Whitacre, constant visits to AmCare, in her case just for Tylenol, made her vulnerable. When she informed a manager she had a shoulder injury, he criticized her production output rather than suggest she go to AmCare. She stopped visiting the company’s health clinic when she was hurt. Smith and other employees described unsafe working conditions, often exacerbated by broken or missing equipment. Another Texas worker described tearing his shoulder after trying to open a box with the wrong equipment. He said he didn’t file a complaint to OSHA because he missed the 30-day reporting window.

While OSHA requires companies in hazardous industries with more than 10 workers to report logs of all occupational injuries that require more than first aid, clinics like AmCare help suppress those numbers. In a 2015 investigation into New Jersey Amazon warehouses, OSHA found that Amazon failed to report 26 worker injuries. Many of these injuries included shoulder and back pain similar to Andrea’s. In the cases cited by OSHA, these less-severe injuries were normally treated with work restrictions and sometimes medication prescribed through Amazon-approved providers.

“Instead of applying for workers comp when they know you hurt your back, they want you to go to AmCare. I just don’t understand why a company that makes over a trillion dollars can’t pay workers comp.”

“The odds of OSHA getting into an Amazon facility are almost nil,” says Deborah Berkowitz, a former OSHA official in the Obama administration and now a fellow at the National Employment Law Project. “Companies want to be able to say we don’t have injuries that require more than first aid. And the easiest way to do that is to prevent workers from getting medical treatment.”

In the past six years, at least five workers have died while working at Amazon warehouses, according to state and federal OSHA reports. In 2018, Amazon made the “dirty dozen” list of the most dangerous companies to work for, put out annually by National Council for Occupational Safety and Health, an independent worker safety group. “There’s a law that says that companies have to prevent all injuries, serious injuries period. They should have no serious injuries at all,” Berkowitz says. “Workers should be able to go and do their job and come home in the same physical shape they started this morning. There aren’t any new hazards in Amazon warehouses that haven’t existed for a long time.”

Amazon told Mother Jones in an email that it takes worker safety seriously. “For us, one incident is too many and our daily safety trainings and programs are designed to reinforce a quality work environment,” Amazon spokeswoman Ashley Robinson wrote. “All associates should come to work and return home safely, and we take that seriously.”

After returning to work in March 2017, Andrea already felt the pain in her hands returning. Her numbers were dropping, and managers issued multiple warnings that if her numbers didn’t improve, she would be terminated. She wrote an appeal to HR, explaining that her performance was due to her injuries. An operations manager saw the appeal and asked where she wanted to be placed. Andrea suggested the inventory line, which wouldn’t involve gripping and pulling. The manager put her at the loading dock instead.

There, she was responsible for throwing pallets that flowed out of the warehouse into the docks onto trucks. The pace was slower, but required even more pulling and lifting. She ignored her growing elbow pain and inflammation.

In July 2017, Andrea was on the docks and being pressured to get the boxes on the pallet. After throwing one of the boxes, she felt a jolt of pain in her shoulder, which she immediately could tell was more serious than the chronic pain she had been enduring. She visited the warehouse’s AmCare clinic for a week, receiving hot and cold therapy. But even with increased breaks, she was in pain. The next weekend she was referred out to a doctor by a manager at Amazon. This time, she was able to take approved leave time and receive temporary disability through Amazon’s claims insurance company.

Finally, in October, she was sent back to work with restrictions. In a document dated November 2017 that Andrea provided to Mother Jones, Sedgwick, Amazon’s insurance company, accepted liability for her neck and right shoulder injury. According to a medical report, Sedgwick provided physical therapy for her neck but did not approve of epidurals requested by her doctor. Sedgwick’s decision was upheld by a California Department of Industrial Relations review board.

But she wasn’t getting better with just physical therapy. Andrea began to suspect that her doctor was more concerned with keeping her on the job. Several workers who spoke to Mother Jones expressed the feeling that doctors they were referred to by Amazon did not have their best interests in mind and, in some cases, seemed to be more concerned with clearing patients for work than treating them. “They call them Amazon’s bitches,” Andrea says of the doctors she was originally referred to by the company. “They make you feel like you’re crazy. They’ll kind of make you feel like a crybaby if you keep pushing it.” (Amazon spokesperson Ashley Robinson responded to this claim in an email, writing, “That’s not true. We follow all state laws.”)

On November 31, 2017, Andrea went to Amazon’s doctor one last time. When he refused to reduce her hours, she asked for an MRI, which he also denied, claiming she’d already had one. (Andrea’s medical paperwork substantiates her claim that at this point, she had not gotten an MRI through Amazon’s insurance.) Finally, in December, depressed, defeated, and in immense pain, she asked her own doctor to put her on state disability for clinical depression. She never returned to Amazon.

“Workers should be able to go and do their job and come home in the same physical shape they started this morning. There aren’t any new hazards in Amazon warehouses that haven’t existed for a long time.”

As her doctor continued to request more treatment for her pain, including epidurals, Sedgwick continued to deny her claims. An orthopedic surgeon found two bulging discs in her neck and nerve damage spreading from her neck through her hands and wrists. Finally, in May, she received an MRI on her neck. The physician agreed to by Amazon and her lawyer discovered extensive nerve damage but ruled that she wasn’t a candidate for surgery. The examiner concluded that Amazon had zero financial liability for her neck. Her wrist, he concluded, was only worth roughly $750 in damages. A May medical assessment by a doctor agreed upon by Amazon and Andrea’s lawyer determined that 25 percent of her injuries were the result of her time at Amazon.

All this time, Andrea had been collecting workers’ compensation. But last July, Amazon requested she return the amount she had received for June—a little over $1,000—citing the May medical report. (Amazon says this was due to an administrative error and it is re-evaluating its process to prevent any further issues.) Her pain was still severe: She had inflammation, tendinitis, and a mass of strained muscles. Her injury exacerbated a decades-long struggle with depression and anxiety. According to an October legal settlement between Amazon and Andrea, she was awarded $7,000 on the condition that she quit and bring no future claims against the company.

What was left after legal fees was just $4,900, a sum she’s already spent on medical payments—$2,000 on a chiropractor in Burbank, $3,000 on alternative therapies, and $2,000 on other necessities such as massages and out-of-network doctors. She’s back in school full-time now, studying to be a drug rehabilitation counselor, something she’s paying for through a voucher she received through a California state program that provides job displacement benefits to workers who are left partially disabled by a work injury and not offered other employment by their company.

Andrea hopes that she can find a decent job after graduating so she can continue to pay for her treatments. But even more than a year since her last day at Amazon, she’s still in constant pain. “Amazon was just a part-time job. It was never my career,” she says. “And that’s maybe the most depressing aspect.”