Portside

TAYLORSVILLE, N.C. — Sheri Farley walks with a limp. The only job she could hold would be one where she does not have to stand or sit longer than 20 minutes, otherwise pain screams down her spine and up her legs.

“Damaged goods,” Ms. Farley describes herself, recalling how she recently overheard a child whispering to her mother about whether the “crippled lady” was a meth addict.

For about five years, Ms. Farley, 45, stood alongside about a dozen other workers, spray gun in hand, gluing together foam cushions for chairs and couches sold under brand names like Broyhill, Ralph Lauren and Thomasville. Fumes from the glue formed a yellowish fog inside the plant, and Ms. Farley’s doctors say that breathing them in eventually ate away at her nerve endings, resulting in what she and her co-workers call “dead foot.”

A chemical she handled — known as n-propyl bromide, or nPB — is also used by tens of thousands of workers in auto body shops, dry cleaners and high-tech electronics manufacturing plants across the nation. Medical researchers, government officials and even chemical companies that once manufactured nPB have warned for over a decade that it causes neurological damage and infertility when inhaled at low levels over long periods, but its use has grown 15-fold in the past six years.

Such hazards demonstrate the difficulty, despite decades of effort, of ensuring that Americans can breathe clean air on the job. Even as worker after worker fell ill, records from the Occupational Safety and Health Administration show that managers at Royale Comfort Seating, where Ms. Farley was employed, repeatedly exposed gluers to nPB levels that exceeded levels federal officials considered safe, failed to provide respirators and turned off fans meant to vent fumes.

But the story of the rise of nPB and the decline of Ms. Farley’s health is much more than the tale of one company, or another chapter in the national debate over the need for more, or fewer, government regulations. Instead, it is a parable about the law of unintended consequences.

It shows how an Environmental Protection Agency program meant to prevent the use of harmful chemicals fostered the proliferation of one, and how a hard-fought victory by OSHA in controlling one source of deadly fumes led workers to be exposed to something worse — a phenomenon familiar enough to be lamented in government parlance as “regrettable substitution.”

It demonstrates how businesses at once both suffer from and exploit the fitful and disjointed way that the government tries to protect workers, and why occupational illnesses have proved so hard to prevent.

And it highlights a startling fact: OSHA, the watchdog agency that many Americans love to hate and industry often faults as overzealous, has largely ignored long-term threats. Partly out of pragmatism, the agency created by President Richard M. Nixon to give greater attention to health issues has largely done the opposite.

OSHA devotes most of its budget and attention to responding to here-and-now dangers rather than preventing the silent, slow killers that, in the end, take far more lives. Over the past four decades, the agency has written new standards with exposure limits for 16 of the most deadly workplace hazards, including lead, asbestos and arsenic. But for the tens of thousands of other dangerous substances American workers handle each day, employers are largely left to decide what exposure level is safe.

By contrast, OSHA has two dozen pages of regulations just on ladders and stairs.

“I’m the first to admit this is broken,” said David Michaels, the OSHA director, referring to the agency’s record on dealing with workplace health threats. “Meanwhile, tens of thousands of people end up on the gurney.”

Royale Comfort Seating disputes that Ms. Farley’s health problems and those of some other workers were linked to their jobs. Company officials also say that while they have sought to safeguard their workers, they have also feared losing jobs to foreign competitors, as many of their industry counterparts in North Carolina have.

Royale has not switched away from the nPB glues, managers said, because alternatives did not work well, were sometimes more dangerous and were almost always more expensive.

“We, as a company, are also in a tight spot,” said William Lee Isenhour, Royale’s director of personnel and safety.

Chronic ailments caused by toxic workplace air — black lung, stonecutter’s disease, asbestosis, grinder’s rot, pneumoconiosis — incapacitate more than 200,000 workers in the United States annually. More than 40,000 Americans die prematurely each year from exposure to toxic substances at work — 10 times as many as those who die from the refinery explosions, mine collapses and other accidents that grab most of the news media attention.

Occupational illnesses and injuries like Ms. Farley’s cost the American economy roughly $250 billion per year because of medical expenses and lost productivity, according to government data analyzed by J. Paul Leigh, an economist at the University of California, Davis, more than the cost of diabetes or chronic obstructive pulmonary disease. Roughly 40 percent of medical expenses from workplace hazards, or about $27 billion a year, is paid by public programs like Medicare and Medicaid.

And yet the full price of this epidemic is measured not just in hospital bills and wages lost, but also in the ways, large and small, that life has changed for Ms. Farley and other sickened workers. Glue fumes robbed her of dignity and the joy of small comforts. Her favorite high heels stay in her closet because her feet no longer cooperate. She barks at her 8-year-old daughter, Allie, for hopping around their double-wide trailer because the floor’s vibrations cause intense stinging.

“I did the work,” Ms. Farley said about her years putting together furniture for America’s households. “This doesn’t seem a fair price to pay.”

Foam Country

Two industries converge in North Carolina along the nine-mile stretch of Interstate 40 between Hickory and Claremont. Foam meets furniture here. Cushions find seats.

For nearly a century, towns in these western foothills have been famous for their fine home furnishings, producing roughly half the chairs and tables sold nationwide at the industry’s peak in the 1980s. Every year, several million pounds of a flexible polyurethane foam known as slabstock arrives. It becomes the spongy filling in most of the mattresses, chairs and couches produced in the United States.

Delivered as huge yellow or pink loaves, often about four feet high and the length of a tractor-trailer, the slabstock is cut into pieces and glued into shapes by rows of workers standing in booths. They sometimes attach upholstery or add a top layer of polyester fiber to give the cushions a softer feel.

North Carolina has been especially affected by globalization and federal regulations. Shifting cultural mores and rising cigarette taxes have cleared hundreds of tobacco farms. Foreign competition has closed most of the textile mills. More than half of the furniture jobs once based here are now gone, according to federal labor data.

Still, about a thousand people spread across several dozen plants in the state work in this locally vital industry. For Ms. Farley, the job at Royale making cushions represented something rare: a chance for someone with little more than a high school diploma and an ability to stand on her feet all day to make more than $9 an hour.

Day 1 at the job brought ominous advice. Don’t dally, co-workers counseled her; managers keep track of your cushions per hour. Bring a hair dryer; it helps in warming brittle hands in winter when the plant gets frigid. Stock up on aspirin and tissues: the first to survive the headaches from the glue’s gasoline-like fumes; the second because the fumes clear the sinuses.

Asked about the conditions, Royale officials said their three plants, two here in Taylorsville and one about 15 miles away in Conover, were no worse than others in the business.

But no one denied it was dirty, bone-tiring work. During 10-hour shifts, the gluers held spray guns attached to hoses that ran to a humming compressor and 55-gallon drums filled with the glue. Once sprayed, the glue coated everything — the lights, fans, floors and electrical outlets — and hung over the workers’ cubicles like a shroud.

“It puts the fog in your head,” Ms. Farley said. By the end of a shift, the glue left some workers so dizzy that they walked as if they were drunk. At times, they did not remember driving home.

A Chemical’s Use Grows

Cushion-making companies had every reason to like nPB glues. First marketed in the late 1990s, they were inexpensive, strong, fast-drying and, best of all, unregulated.

“It’s so safe you can eat it,” glue salesmen in North Carolina told customers, according to federal researchers. Plant operators joked, “At worst, it’s a cheap high,” an official from an industry trade association recalled. Water-based glues, though safer, dried slower. And retooling a plant to use them could cost anywhere from several thousand dollars to more than $1 million, in some cases doubling a company’s gluing costs.

Finding a glue that complied with federal rules was a continuing struggle. In the early 1980s, many companies used glue with a chemical called 1,1,1-trichloroethane, or TCA. But the United States and other countries then banned it because it damages the ozone layer, and businesses switched to methylene chloride.

Nicknamed by cushion makers “methyl ethyl bad stuff,” it killed more than 30 workers a year and sickened thousands more across all industries. OSHA tightened safety limits on the chemical, so companies sought a new option. Before long, roughly a third of the cushion-making industry had switched to nPB-based glues.

For the most part, American employers are left on their own to find substitutes when federal agencies impose new rules on chemicals. But when the government forces the phasing out of one hazardous chemical, it is often replaced by another equally or more dangerous one.

From the start, government officials worried about the safety of nPB, which is also sometimes called 1-bromopropane or 1-BP.

In 1999, Adam Finkel, OSHA’s top health officer who had led the agency’s drive to phase out methylene chloride, wrote a letter warning that nPB was being used as a replacement at levels 10 to 200 times what chemical companies said was safe. Something needed to be done, he said, before the number of people exposed to the new chemical “grows from the hundreds to the tens of thousands or more.”

Some companies pulled back. Protonique SA, a Swiss circuit-board maker, banned it for its workers, who used a form of the chemical that was less toxic than that inhaled by Royale workers. “There is a weight of evidence that should sound warning bells to any thinking person,” the company said in 1999. By 2003, Atofina and Great Lakes, two large chemical companies, had decided they would no longer sell nPB.

In the six years after Mr. Finkel wrote his warning letter, federal authorities learned that more than 140 cushion workers nationwide, mostly from plants in Utah, Mississippi and North Carolina, including Royale, had been exposed to dangerous levels of the chemical, many of them sickened and unable to walk.

Cushion makers in the 30,000-employee foam industry were among the most vulnerable of all workers using nPB because they breathed it in aerosol doses. Those employed in other businesses mostly used it in other forms, which pose lower risks, according to scientists, who are finding mounting evidence that nPB is also a carcinogen.

Pinpointing the cause of a worker’s ailment is an inexact science because it is so difficult to rule out the role played by personal habits, toxins in the environment or other factors. But for nearly two decades, most chemical safety scientists have concluded that nPB can cause severe nerve damage when inhaled even at low levels.

Ms. Farley sued Royale for workers’ compensation payments. Her case, along with several other lawsuits related to glue fumes brought by other workers, has been settled.

When news of exposure problems at Royale reached officials at Mid South Adhesives, the maker of the glue that Royale used, they sent an inspector who found that Royale’s Conover plant showed levels at least 10 times what Mid South deemed safe. Mid South officials wrote to Royale to say they could “not stress enough” the need to provide better protections or to stop using their glue.

Royale officials, though, responded that even though they had added fans, had trained workers handling toxic chemicals and planned to put in a new ventilation system, problems persisted.

“We tried to use a water-base adhesive, which did not work for us,” a Royale official wrote, adding that the company saw no alternative but to stick with nPB glue.

Other companies were also reluctant to switch from nPB glues. Officials of the Franklin Corporation, a cushion plant in Houston, Miss., explained in court documents that safety was important but that nPB glues were attractive because they dried so fast that the cushions could be produced in a third of the time.

“There are people lined up out there for jobs,” said John Lyles, a vice president at Franklin, according to testimony by a plant manager in a successful lawsuit in Mississippi brought by four cushion workers who suffered severe nerve damage from the glue. “If they start dropping like flies, or something in that order, we can replace them today.”

Businesses found nPB appealing partly because the E.P.A. had given it an endorsement of sorts by adding it to a list of chemicals that do not harm the ozone layer. But an unintended effect of that action was to allow sellers of the chemical to market it as federally approved, “nonhazardous,” green and worker-friendly.

As the chemical’s popularity grew, E.P.A. officials worried about its use in spray glues, especially in cushion-making factories where the agency had determined that even with “state of the art” ventilation, “nPB-based adhesives cannot be reliably used in a manner that protects human health.”

Environmental officials figured that OSHA, pressured by the Bush administration and Republican lawmakers to be more business-friendly, would not be capable of policing the growing threat. “OSHA is tough,” E.P.A. officials said, according to notes from a November 2006 meeting on concerns about nPB. “But their budget is small, and they are not going to crack down on small businesses.”

OSHA has never set a standard establishing safety limits on workers’ exposure to nPB. The E.P.A. recommended such a limit and considered banning the nPB glues, but it has yet to finalize the plan. It determined that most cushion companies using the glue had fewer than 100 employees, which meant they were less able to absorb the cost of another regulation.

“There just wasn’t the political will,” an E.P.A. official who was part of the decision-making said on the condition of anonymity.

Improvised Remedies

A single tattered page from a 2005 workers’ compensation log summed up the emerging situation at Royale. Beneath a column headed “Injury or Illness” stretched a dozen rows, each reading “Alleged Neurological Injury” — one for each worker in the Conover plant sickened in the first three months of the year. Each missed more than 40 days of work because of the glue fumes, which were especially intense after the company moved the work stations closer together.

Thousands of additional pages of court and government documents, as well as interviews with more than two dozen current and former employees — some speaking on the condition of anonymity — present a fuller view of the conditions in the plant and how things got that way.

By 2005, Efrain Robles Avila was using a walker because he could no longer stand on his own, according to medical records. Victor Gonzales, a father of three, needed help putting on his clothes because he had lost control of his hands. Laura Garcia, who had worked for Royale for less than a year, complained of a cold numbness running from her waist to her toes. “It was like your legs didn’t receive the signal when you had to walk,” she said in court documents.

The numbness was dangerous. One worker recounted meeting a neighbor who asked why she was wearing a single red shoe. Only then did the worker realize her foot was bleeding profusely from a two-inch gash.

Inside the plant, workers improvised. Some stood on scrap pieces of foam to cushion their feet and ease the stinging sensation creeping up their legs. One, Sonia Richards, arrived with her own respirator, but a manager told her to put it away, saying it was spooking other workers. In whispers, new employees were warned to visit the bathroom whenever the fog grew thick.

“If you don’t clear your head,” a worker recalled being told, “it will clear you.”

Royale is among the industry’s most dangerous businesses, according to OSHA data. Federal officials found that it had exposed workers to dangerous levels of nPB at least a dozen times, more often than any other company. Since 2002, nearly three dozen Royale workers have been found to be breathing dangerous levels of glue fumes, federal records show.

Current and former employees say the number of workers sickened is most likely double that, since OSHA visited only periodically and turnover was high.

Some buyers of Royale cushions said they knew generally of the dangers of nPB, but expected their suppliers to take all required precautions. Lisa Hanly, vice president of Furniture Brands, which handles Broyhill and other well-known furniture, said, “Our goal is to produce high-quality product, which meets all legal and safety requirements, at an affordable price.” She said the company’s inspections focused on suppliers overseas, where regulations are weaker than in the United States. Other companies that buy from Royale declined to comment.

Royale workers became regular visitors at local health clinics, including the Clinic for People Without Health Insurance, then run by Dr. Ben Wofford.

Looking like “upright cadavers,” Dr. Wofford said, cushion workers arrived unable to stand on their own, supported under their arms by family members. They had showered and changed out of their work clothes, he said, but their breath still carried an odor he remembered from his boyhood days putting together model airplanes.

He had watched for years as his patients’ suffering worsened with the bottoming out of the state’s tobacco, textile and furniture industries. When people are out of work, he explained in an interview in his office above the pharmacy in Newton, N.C., a diabetic ulcer that would normally cost a toe takes a leg. Their nonfatal hernia bleeds them to death.

“You kill jobs,” Dr. Wofford said, “you kill patients.”

Reluctantly, he wrote a letter in 2005 alerting OSHA about problems at Royale. One worker was in especially bad shape, he wrote: “Indeed he may die as a result of his exposure.”

But Dr. Wofford also urged OSHA not to overreact. “I would hate to see this plant’s multiple shortcomings result in its being shut down,” he wrote, warning of jobs that could be lost. “Many are my patients and are already in dire straits economically.”

Referring to one woman who was the sole support for herself and three children, he wrote, “She too is unlikely to find work if the effects of the neurotoxin are irreversible, as my neurological consultant thinks they may be.”

Over the years, officials with Royale, which employs about 100 workers and had around $7.5 million in sales in 2011, have repeatedly said they have done all they can to make their three plants safe. They frequently took steps to improve the air in their plants, but their actions were also sometimes counterproductive — after improving ventilation, they failed to change filters, for example, or covered vents with plastic in the winter to keep out cold air, according to OSHA documents.

In a recent interview, Mr. Isenhour, Royale’s safety director, said the company never meant to harm anyone and initially did not realize the hazards of nPB. Royale has continued using nPB glues, he added, because alternatives are ineffective or risky.

Glues that use acetone, for example, are popular but highly flammable, he said. Converting the Royale plant to meet federal rules on fire safety would entail replacing the glue-spraying booths with metal walls, installing sprinklers and explosion-proof lighting and retraining workers, at a cost of tens of thousands of dollars, he added.

In 2005, when seven workers became seriously ill at one plant, Mr. Isenhour said, Royale had to lay off 40 people, close the facility and spend $50,000 to move operations to another site and upgrade the ventilation there. OSHA found high levels of fumes in subsequent years because no one informed the company that fans and filters needed cleaning for ventilation to work properly, he said.

If the company switched to a more expensive glue, he said, he would have to raise the price of each cushion, and the furniture makers Royale supplies would contract with Chinese competitors instead.

“We are trying to keep jobs in America,” he said. “But that’s expensive.”

Both government officials and employers weigh the costs and benefits of protective measures. Many studies show that investing in workplace safety saves money in the long run, but economists say that does not prove true in every case. This, of course, raises the most difficult calculus of all: comparing the worth of a dangerous job versus no job at all. How should companies and regulators put a dollar value on workers’ quality of life — indeed, on their very lives?

To date, Royale has paid nearly a half-million dollars — in court settlements, required upgrades and less than $20,000 in OSHA fines related to glue fumes. Those costs — and the harm to workers — accumulated in slow motion. Cushion making is a boom-bust business, subject to the swings of big orders from furniture companies. Royale and others in the industry frequently use transient, nonunion and illegal immigrant laborers, according to workers and court documents, who are less likely to report hazards and document symptoms.

As fast as workers were getting sick, managers found replacements.

“Folks was limping in and getting worse,” said Dewaun Teague, a former Royale manager. “Then they would be let go, and we would hire more.”

Mr. Teague said Royale was a good company to work for in many ways. The owner, Clyde Goble, looked you in the eye when he shook your hand and remembered your children’s birthdays, Mr. Teague said, adding, “This was family.”

Complain. Inspect. Repeat.

After receiving an anonymous complaint about glue fumes, Beverly Stone, an OSHA inspector, visited a Royale foam cushion plant in Taylorsville in May 2011. She toured the facility, tested the air and then filed a lengthy report.

“Ventilation did not appear to be working properly,” it said, adding that at least 16 workers were breathing dangerous levels of glue fumes.

Worrisome enough on their own, Ms. Stone’s findings were even more alarming because they were so similar to what OSHA documented in 1996, 2000, 2002 and 2005.

Again and again, Royale workers got sick and contacted OSHA. Inspectors came and went. Little changed.

Company officials were told to ventilate to the outside. They bought pedestal fans instead, and when OSHA inspectors returned, they found the fans turned off or malfunctioning. OSHA demanded respirators that would have cost the company $18. Managers instead handed out 90-cent dust masks — the type inspectors had told them were useless in blocking vapors.

The agency advised the company to stop using nPB-based glues. And yet, each time inspectors showed up, they found more workers exposed to the chemical and at levels higher than what the glue companies were saying was safe.

Back and forth it went, as workers fell victim not just to toxic air but also to a federal agency’s inability to enforce its requirements.

While agency inspectors consistently showed up within a day of receiving worker complaints, records show, they often did with one hand what they undid with the other. Sometimes they failed to levy fines because they did not believe they had the authority. Other times they undermined their own leverage by slashing the size of penalties in hopes of promoting cooperation from the company.

After each visit, the agency suggested abatements but never did follow-up air tests and appeared again only when sick workers complained.

For its part, the company shuffled workers among its three plants in the frustrated hope that one of the sites might have better air flow. But the constant movement of these workers from plant to plant also made repeat problems look to regulators like isolated cases.

In early 2011, when Royale officials realized that they could not fix the ventilation at the Taylorsville plant where Ms. Farley worked, they moved her and a half-dozen other workers to the other Taylorsville site. Ms. Farley’s symptoms grew worse there; the ventilation problems had been identified by OSHA in 2002 but never corrected.

If inspections are supposed to force companies to rectify problems and avoid future ones, that 2002 inspection was a failure. “Not able to require the employer to implement engineering controls,” the OSHA official wrote at the time, adding that the agency could not levy fines or mandate respirators because there was no federal safety standard involving nPB.

That was a legal judgment call, one that many workplace safety experts say illustrates OSHA’s unwillingness to exert its full authority. Though the agency has the legal means to force companies to protect workers better from certain chemicals even when there is no specific exposure level established by the agency as safe, OSHA rarely invokes this power for fear of sapping limited resources if the matter ends up in court.

“We do the best we can,” said Kevin Beauregard, an assistant deputy OSHA commissioner in North Carolina, which is among 25 states deputized by the federal government to oversee worker safety programs. He said that before his office could act in such instances, it must first prove that workers were exposed to a substance whose hazards were recognized in the industry and that the exposure was avoidable.

OSHA also rates health hazards as a lower priority than safety threats. In 1996, for instance, inspectors discovered that a machine part hit a Royale worker in the groin. The agency threatened to fine the company a total of $120,000, adding $5,000 to the fine for each day that the company failed to repair the machine. But when nPB levels remained high during five visits between 2002 and 2011, the agency never increased the penalties. The proposed total for all of Royale’s health-related fines was $20,800, an amount the agency later lowered.

Partly, the emphasis on safety enforcement is a numbers game. OSHA’s performance is often measured by lawmakers, advocacy groups and the news media based on how many inspections it does in a year; an inspector can do five times as many safety inspections in the time it typically takes to do one focused on health, where the issues may be less clear-cut. And the agency tends to face less public pressure about health enforcement, because the harm done by these sorts of hazards typically does not show up for years.

Furthermore, while the number of inspectors has grown under the Obama administration, OSHA still has just 2,400 responsible for overseeing roughly eight million work sites — roughly one inspector per 60,000 workers, a ratio that has not changed since 1970. The federal budget for protecting workers is less than half of that set aside for protecting fish and wildlife.

Mr. Michaels, whose tenure leading OSHA since December 2009 has been characterized by more aggressive enforcement than that of his most recent predecessors, cites a deeper problem: the small amount that OSHA can levy in fines. The maximum penalty for a violation that causes a “substantial probability of death — or serious physical harm” is $7,000. The highest fine for a willful and repeated violation is $70,000.

This, Mr. Michaels said, pales in comparison with fines of up to $130,000 that the Department of Agriculture can levy if a dairy company refuses to pay fees that help the federal government advertise milk products, or the $325,000 that the Federal Communications Commission can fine a TV or radio station for indecent content.

“If the cost of compliance to our rules outweighs the penalties for breaking them, companies just take a ‘catch me if you can’ approach to worker safety and health,” he said. And serious violations of the rules should not be misdemeanors, he said, but felonies, much like insider trading, tax crimes and antitrust violations.

But Jeff Ruch, the director of Public Employees for Environmental Responsibility, a public health advocacy organization, said that, on average, OSHA now conducts health inspections and collects air samples less than half as often as it did under the Reagan administration.

“You can’t hit someone with a fine,” Mr. Ruch said, “if you aren’t on site looking to find the violations.”

Hard Calculus

As her truck crawled down a bumpy dirt road, Ms. Farley said she needed to go slowly because she could not afford to replace her duct-taped bumper if it fell off. Between money from breeding her four Rottweilers, food stamp assistance and the occasional help from her ex-husband or the local food bank, her finances leave little room for error.

She stopped in a field dotted with narrow white trailers to pick up Cosondra Little, another former Royale worker, who limped as she approached. Ms. Little lives with her 24-year-old daughter, SoSonia, who is unemployed. What fresh tomatoes, collard greens and other vegetables the two eat come mostly from scavenging on nearby fields when farmers allow it. This has been the case, Ms. Little said, ever since she lost her job at the cushion plant in May 2003.

“My feet started to throw a fit,” she said. First went her health insurance, then money for SoSonia’s college tuition, then their savings, and finally the car.

“You try getting a job around here without a car,” Ms. Little said, riding along a wooded stretch of Highway 16 just south of Taylorsville.

Soon the two women arrived at Martha Cardenas’s house, where they were joined by two others, one a former cushion maker, the other a current one. They had gathered to explain that Royale is not unique.

After small talk about Ms. Cardenas’s empanadas, the women stacked their medical records on the table. Different plants, different doctors, same glue. Broken lives reduced to physicians’ scribbles. “Staggered gait,” “numb hands and feet,” “spinal pain.”

Usually the same medical advice, too: find a different job; stop working with the glue. It “has been clearly documented as a cause of” nerve damage, Ms. Little’s doctor wrote to her boss about nPB.

But other jobs are hard to come by. And that is why everyone has wanted to keep Royale in business. “Now none of us are working,” Ms. Farley said. In Dr. Wofford’s hesitant whistle-blower letter to OSHA, in a $50,000 loan that county officials gave to Royale, in OSHA’s formula for lowering fines, there were vexing calculations seeking to strike the right balance between protecting jobs and safeguarding those holding them.

In Ms. Cardenas’s house, the women were doing some math of their own. One tried to tally how many hours she had spent in the unemployment office. Another added up her credit card debt and counted her doctors’ visits. But mostly the women listed the subtler costs of their injuries, like the pounds gained from immobility or the addiction concerns with pain pills.

As the women stood up to leave, several grabbed the wall for balance. Ms. Farley added a parting thought.

“And all the while everyone thinks you’re just faking,” she said. The women agree that this is the worst part.