HIV/AIDS in Manufacturing and Construction Companies in Ekurhuleni
HIV/AIDS in Manufacturing and Construction Companies in Ekurhuleni
HIV/AIDS in Manufacturing and Construction Companies in Ekurhuleni David Dickinson (Wits Business School) And Marije Versteeg (Madibeng Centre for Research)
2 Executive Summary This report examines the impact of HIV/AIDS on manufacturing and construction companies based in Ekurhuleni and the response of companies to the threats posed by the disease. Three manufacturing companies located within Ekurhuleni and two national construction companies with activity in Ekurhuleni were researched. A total of 31 face-to-face interviews were conducted at company offices or operations, including construction sites in addition to a small number of telephonic interviews with a range of stakeholders.
Relevant company and industry documents were also used when access was granted.1 A small number of relevant meetings at company and industry level were attended by researchers. The Impact of HIV/AIDS Features of the manufacturing and construction industries result in different HIV/AIDS risks and different challenges in mounting effective workplace responses to the disease. Nevertheless, a number of common issues can be identified in regard to the two industries and HIV/AIDS. One shared feature is the lack of accurate information as to the extent of the problem faced by companies. Following on from this uncertainty is confusion as to how operations will be affected by HIV/AIDS.
The potential impact of HIV/AIDS on skills is probably of greatest priority to management. This needs to be placed in the context of wider skills shortages. In both industries it is higher-skilled, blue collar occupations where skill shortages are most acute and where it is feared that HIV/AIDS will have most impact. Within manufacturing this presents problems for companies seeking more efficient manufacturing practices. Within the construction industry it presents problems for its core hourly-paid workforce that forms the backbone of site-based operations.
Absenteeism associated with HIV/AIDS also presents a potential problem especially for manufacturing companies attempting to operate ‘high performance’ workplaces.
The impact on employee benefits presents a complex picture that cannot be understood without taking into account the differentiated systems of social protection operating. More skilled and better-paid employees are at relatively low risk of HIV/AIDS infection but have more comprehensive medical and insurance benefits. While there is likely to be a high incidence of HIV/AIDS among lowest -skilled workers they have very weak systems of social protection; a situation that presents relatively little risk to companies since the cost of HIV/AIDS is borne entirely by individuals, families and the state’s social protection network.
It is the social protection structures of semi-skilled workers that present the greatest systemic risk either because of inadequate healthcare for workers or because of the vulnerability of the industry-based benefit schemes. The emerging tensions (and potential crises) around employee benefits, particularly for semi-skilled workers presents potential industrial relations conflicts. Additionally, a second political economy tension is exposed by these issues; the responsibility of employers and the state to provide health care for employees. Company Responses to HIV/AIDS In the face of emerging threats from HIV/AIDS it is clear that companies in both the manufacturing and construction sector and now mounting workplace responses to the disease.
The response in manufacturing companies is clearly ahead of construction.
In so far as workplace responses have been mounted in construction companies the most immediate problem is the logistical difficulties of running programmes with geographically diverse and changing configuration of activity along with an extremely rapid turnover of employees. In addition to these challenges the nature of 1 Access was generally, but not always, granted. Sometimes documents were promised but then not forthcoming. One company felt unable to provide the researchers with their Employment Equity Plan, despite this being a public document. The document was subsequently obtained directly from the Department of Labour.
3 these workplaces contributes to the risk of HIV infection. The migrant nature of the core workforce (between sites and between sites and families), single sex accommodation, the system of monthly payment on leave weekends, and the relative wealth of employed individuals near poor communities all constitute potential risk factors. The more advanced nature of workplace HIV/AIDS programmes in manufacturing allows a greater analysis of their strengths and weaknesses. The key components of a workplace HIV/AIDS programme are largely (if not fully) understood by most managers responsible for company responses to HIV/AIDS: awareness and education, peer education structures, voluntary counselling and testing, wellness and treatment programmes, and corporate social responsibility initiatives.
The report highlights a number of limitations and tensions associated with these programme elements.
Education and awareness around HIV/AIDS is often approached in a heavy handed didactic fashion. The view underlying this approach – that information will lead to behaviour change – fails to take into account not only the resilience of behavioural norms (and constraints) but also the late nature of current interventions. Interventions need to understand both the cultural context of the intended recipients and the pre-existing beliefs that have been formulated prior to the arrival of those seeking to impart information. Peer educators provide a powerful educational mechanism. However, it would appear that peer educators are sometimes regarded as a ‘cheap option’ by management.
The reaction (or lack of reaction) among some sections of the workforce is, in part, a response to this approach. It also exposes the important fact that HIV/AIDS workplace programmes have to be mounted within often tense industrial relations environments. By and large, even the more advanced workplace HIV/AIDS programmes of the manufacturing companies researched had made limited attempts to introduce VCT programmes. The absence of any treatment offered by companies presents a barrier to the likely success of VCT programmes. This presents a ‘chicken and egg’ situation in that it is difficult to obtain senior management commitment on the provision of anti-retroviral drugs, while the lack of such provision limits the success of VCT interventions that could be used to justify such expenditure.
The provision of health services in general constitutes a complex set of problems for companies. There is recognition that attention has to be given to this area, but there appears to be no consensus on how this should be approached. Industrial nurses are, despite their professional status, often marginal to managerial structures and HIV/AIDS programmes. The state’s provision of health care is limited and relatively difficult for workers to access. Traditional healers, despite being an important resource for many African workers, are totally excluded from company healthcare strategies.
Improving Company Responses to HIV/AIDS Perhaps the major challenge facing companies in responding to HIV/AIDS is not the question of resources (though this is critical) but the ability to co-ordinate a wide range of internal and external agents who can deliver elements of an effective workplace HIV/AIDS programme.
The limited involvement of unions, industrial nurses, and traditional healers, along with tensions around the mobilisation of peer educators, point to limitations in workplace programmes. Further, the almost total lack of co-ordination between companybased and public health provision points to limited co-ordination around responsibility for the national response to HIV/AIDS.
A number of recommendations for interventions and further research directed at addressing the problem identified are put forward in Section 4 of the report.
4 Contents Executive Summary Glossary of Terms 1. Introduction 2. Manufacturing 2.1The Companies Researched 2.2 The Research Conducted 2.3 HIV/AIDS Prevalence in the Companies 2.4 The Impact of HIV/AIDS 2.4.1 Skills 2.4.2 Absenteeism 2.4.3 Employee Benefits and Social Protection 2.5 Company Responses to HIV/AIDS 2.5.1 The Response to Date 2.5.2 Programme Components 22.214.171.124 Awareness & Education 126.96.36.199 Peer Education 188.8.131.52 Voluntary Counselling and Testing (VCT) and Treatment 184.108.40.206 Corporate Social Responsibility: Glossy and Safe or Local and Difficult? 2.5.3 Health Resources 220.127.116.11 Industrial nurses 18.104.22.168 Public Sector Health Provision 22.214.171.124 Traditional Healers 2.6 Process, Actors and Capacity 3.
Construction 3.1 The Companies Researched 3.2 Research Conducted 3.3 The Construction Industry 3.4 HIV/AIDS Prevalence in the Companies 3.5 The Impact of HIV/AIDS 3.5.1 Skills 3.5.2 Absenteeism 3.5.3 Employee Benefits and Social Protection 3.6 Company Responses to HIV/AIDS
5 3.6.1 The Response to Date 3.6.2 Programme Components 3.6.3 Health Resources 3.7 HIV/AIDS and the Cyclical and Geographically Diverse Nature of the Industry 3.8 Limited Duration Contract Workers, the Construction Industry and HIV/AIDS 4. Summary and Recommendations 4.1 Summary 4.2 Recommendations 4.3 Suggestions for further research References
6 Glossary of Acronyms AIDS Acquired Immuno Deficiency Syndrome CIRBF Construction Industry Retirement Benefit Fund CIDB Construction Industry Development Board CSR Corporate Social Responsibility (also CSI – Corporate Social Investment) EMM Ekurhuleni Metropolitan Municipality HIV Human Immunodeficiency Virus HR Human Resources KAP Knowledge, Attitudes and Practices (survey) LDC Limited Duration Contract (i.e.
fixed-term employee) NUM National Union of Mineworkers SAFCEC South African Federation of Civil Engineering Contractors STI Sexually Transmitted Infection (or STD – Sexually Transmitted Disease) TB Tuberculosis VCT Voluntary Counselling and Testing
7 Section 1: Introduction This report summarises the findings of a qualitative research conducted in Ekurhuleni-based manufacturing and construction companies. It provides a detailed, though narrowly focused, addition to the background paper (Dickinson 2004) written for Ekurhuleni Metropolitan Municipality (EMM) Local Economic Development Unit which summarised the possible impact of HIV/AIDS on the Ekurhuleni Economy. As outlined in the background paper it is expected that HIV/AIDS will negatively impact on companies – though exactly how this will happen and its magnitude remains uncertain.
Any impact on the Ekurhuleni companies has economic and developmental implications and is important. So too is the response of companies to HIV/AIDS which might be able to avoid, mitigate or control the impact of the disease.
As indicated in Table 1 manufacturing and construction represent a sizable part of the Ekurhuleni economy. Table 1: Contribution of Manufacturing and Construction to the Ekurhuleni Economy Manufacturing Construction Percentage of Gross Geographical Product (GGP) (2001) 29% 4% Percentage of Employment (2001) 25% 8% Source: Kgori, Lebelo, Johannes & Roberts (2002) Given their share of Gross Geographical Product and employment the manufacturing and construction sectors are of importance in themselves. The purpose of this study was, through a small number of case studies, to identify the possible impact of HIV/AIDS in these two sectors and their responses to the disease.
Studying companies from two different economic sectors allows us to compare the impact and response to HIV/AIDS under different circumstances. Section 2 of the report looks at manufacturing and Section 3 construction. Each section outlines the companies and the research conducted before presenting evidence from the case studies. The extent of HIV/AIDS prevalence is assessed and the possible impact of the disease, particularly in terms of skills, absenteeism and employee benefits, is discussed. The companies’ responses to HIV/AIDS are then outlined.
Section 2, dealing with manufacturing companies, draws attention to questions of awareness and education, peer education, voluntary counselling and testing, corporate social responsibility, and available health resources. This section concludes with a discussion on actual and potential processes, actors and capacity that made up the HIV/AIDS workplace programmes observed. Section 3, dealing with the construction industry, emphasises the multi-tiered level of social protection operating within the workforce and the implications of this in regard to HIV/AIDS. It also discussed the key issue of the project nature of construction work and two critical issues that result from this; migration and the widespread use of temporary workers.
Section 4 draws together key issues raised in the case studies and provides a number of recommendations and suggestions for future research.
8 Section 2: Manufacturing 2.1 The Companies Researched Three medium-sized Ekurhuleni workplaces were researched; a plastic conversion company with 250 employees, a beverage company with 100 employees, and an engineering company with 150 permanent and 90 brokered employees on temporary contracts. All shop floor workers – apart from the brokered employees at the engineering plant – were unionised. All three companies had racial divisions of labour common in Gauteng industry; the majority of low and semi-skilled shop floor workers being African, predominantly white artisans, an increasing number of black supervisory staff, and a largely white, male management team (excepting human resources).
Security, canteen and gardening services were outsourced. All three companies had some form of HIV/AIDS response programme in place though this was either newly established, or was being upgraded from previous, lower-level, responses. 2.2 The Research Conducted Qualitative research methods were employed, principally in the form of semi-structured interviews with a range of individuals holding different positions within the companies. Twenty three interviews were conducted across the three companies. Interviews typically lasted for an hour. The principle research also attended company peer educator training sessions in order to directly observe this critical element of the company’s response to HIV/AIDS.
A case study approach cannot be regarded as representative of the population (manufacturing companies in Ekurhuleni) as a whole. However, such as an approach has the advantage of being able to expose and understand dynamics pertinent to the research topic – something which other research methodologies, such as questionnaires, are less able to do.
All companies and individuals were assured of anonymity. To ensure this, names and distinguishing details have been either omitted or changed while taking care not to change the nature of the evidence presented. 2.3 HIV/AIDS Prevalence in the Companies None of the three companies had any accurate measurement of the risk that HIV/AIDS posed to their operations. One company had had an actuarial study2 conducted which predicted a prevalence rate of 10 percent among employees, another company had chosen (more or less randomly) a prevalence rate of 20 percent as a working figure for calculating costs, the third company had no estimated prevalence rate.
2 An actuarial study inputs data on the workforce (such as race, education and age) into a model. This model extrapolates from the national antenatal data (pregnant women attending state hospitals) to the whole South African population based on a number of assumptions that are cross-referenced as best as possible with available studies. This model is then projected back onto the company using its particular demographic profile. Thus, any uncertainties in the national model (and there are a number of competing models that use different assumptions and arrive at different results) will be reproduced at the company level.
Moreover, because of its statistical basis the likelihood that the model's predictions will differ from reality increases the smaller the population considered – a matter of particular concern for small and medium sized companies.
9 In the absence of any reliable measures, companies’ understanding of how HIV/AIDS might impact upon them rest heavily on the visibility of the disease. Given the long incubation period of AIDS and the stigma associated with the disease, visibility is a highly reactive and unreliable indicator. Nevertheless, with a wave of AIDS deaths now breaking over society the disease is increasingly apparent. Company ‘AIDS-related deaths,’3 while the most visible indicator available is clearly in itself not reliable. In one company, three managers – all members of the HIV/AIDS committee – gave different figures in this regard.
One said he knew of no such deaths, a second the figure of four, and a third, the most junior of the three, seven – producing copies of death certificates indicating ‘natural causes’ and ‘diarrhea’ to support this.4 Given the limited visibility and measurement of HIV/AIDS in the workplace it is not surprising that the potential impact of the disease is largely unknown. While managers could report that HIV/AIDS was not having a major impact on current operations there was widespread concern – given uncertainty over HIV prevalence within the workforce – at what the future impact might be. 2.4 The Impact of HIV/AIDS Three areas in which HIV/AIDS was likely to impact on companies were identified as skills, absenteeism and employee benefits.
2.4.1 Skills With regard to the possible loss of skilled workers as a result of HIV/AIDS what was of concern was not the current number of workers thought to be dying of HIV/AIDS (even at the higher end of these estimations) but that this could escalate, possible rapidly, and that key personnel with company-specific skills could be lost. As one manager explained: In the last two years a number of people in the workforce have died...people we worked closely with...it became a reality and there was a realization that there was the potential for skilled operational level employees to be whittled away...We needed to start addressing the issue.
The same manager explained how this possibility had been brought home to him when the company re-employed a shop-floor worker because they again needed his skills. He accepted their offer and was re-employed, but three months later he was ill and subsequently died of AIDS. The fact that new recruits, possibly replacing AIDS losses, might also be HIV positive was a factor that HR managers realized could further impact on skills shortage and the costs of recruitment and training. One company was considering an upgrading of its operations. A concern was, however, that its productive investments would rely on more skilled workers who could be HIV positive when recruited.
3 Deaths are rarely openly acknowledged to be a result of HIV/AIDS. However, observation of illness, sick patterns and an interpretations of the euphemisms used on death certificates allows the drawing of reasonably robust conclusions as to AIDS-related diseases being the cause of death when adults die of otherwise minor or curable complaints. 4 This range of response provides a sobering reflection on questionnaire-based calculations of the impact of HIV/AIDS on companies. Almost inevitably a single source is asked for company data and it is generally assumed that the more senior the source the more accurate the response.
10 2.4.2 Absenteeism All three companies found absenteeism to be a problem, but this was notable more acute in the two operations that had relatively efficient production processes and higher skill profiles. These two companies relied less on substitutable low-skilled labour which could be easily and quickly drawn from the unemployed waiting outside the factory gates in the hope of casual employment. Additionally, one of these companies produced small batch orders to tight deadlines and the other operated continuous flow process – both of which are vulnerable to erratic labour supplies. For these companies absenteeism was a major problem, despite the fact that one of them offered an incentive scheme in which workers were paid for sick leave that they did not take.
Absenteeism has many causes including family responsibilities, the monotonous nature of work, long travel distances on poor public transport, as well as illness. Within an increasingly competitive economy, requiring higher levels of productivity and ‘leaner’ operations, any factor adding to absenteeism is a problem.
Although HIV/AIDS was not credited with being responsible for the bulk of absenteeism it was recognized that the disease was particularly taxing in this regard. A number of managers outlined a now familiar sickness pattern in which individuals would take increasing amounts of leave, perform poorly at work, exhaust sick leave and eventually die of AIDS-related illness. This was disruptive to production and until the individual died or was medically boarded a replacement could not be recruited. Given the unknown extent of HIV prevalence, AIDS-related absenteeism was seen, along with the loss of skills, as the most likely areas where AIDS might impact on company operations.
2.4.3 Employee Benefits and Social Protection Any increase in illness and death among people of working age will have an impact on the viability of ‘social protection’ schemes including risk insurance, provision for retirement and medical cover. The potential scale of the HIV/AIDS epidemic among employees has possible implications for the viability of these schemes.
To understand how this might happen it is first necessary to recognize the two tier-system of social provision that operated in these (and other South African) companies. In a nutshell low-paid workers have lower levels of social protection and are a higher risk group for HIV/AIDS; higherpaid workers have greater levels of social protection and are a lower-risk group. However, the direct risk to companies of HIV/AIDS on employee benefits has been minimized by the structures of social protection adopted. The social protection mechanisms and their two-tier nature are summarized in Table 2.
- 11 Table 2: The Two-tear Provision of Social Protection in the Manufacturing Sector General two-tier provision structure Social Protection Element Mechanism(s) Lower-Income Employees Higher-Income Employees Risk and retirement benefits 1. Private Insurance: employers and employees contributions
- Payment in the event of death or disability while of working age (risk component)
- Payment upon retirement (retirement component)
- May include other insurance elements (e.g. funeral cover) 2. State pension provision/disability grant Low-paid workers join provident schemes
- Provides lump sum payment for incapacity or retirement, generally three times annual salary
- Schemes are run on an industry basis under the control of a joint union/employer representative body
- Universal state provision (low level). No risk cover for pre-retirement age death High-paid workers join pension schemes
- Provides pension (for beneficiaries in the event of risk cover, for member in the event of retirement)
- Schemes are run on a company basis under control of joint management/employee representative body Medical care 1. Medical aid: employers and employees contributions
- Payment for medical costs for member and dependents some co-payments depending on scheme rules
- Provision of anti-retroviral drugs and associated costs through disease management schemes for most medical aid programmes 2. Company-based primary health care: employer pays
- Generally linked to occupational health services
- Limited in provision
- Some large companies now providing anti-retroviral drugs for employees
- Generally limited to direct employees (excluded dependents and sub-contracted workers) 3. State provision: financed through general taxation
- Roll-out of anti-retroviral drugs in early stages Lower paid-workers cannot afford medical aid contributions and rely on company-provided primary health provision and state health care. For employees accessing state health care requires sick leave.
- Other than for basic problems employees access public health care system. Higher-paid workers join medical aid schemes
- Employee and families able to access required health care as required. For employees this minimises need for sick leave.
- Employees and family members generally able to access antiretroviral drugs via disease management programmes.
12 Risk and Retirement More highly paid sections of the workforce contribute to company pension schemes that will provide income for retirement or, should they die, for dependents.
All three companies ran retirement/life insurance schemes for salaried staff and believed these to be at low risk from HIV/AIDS given the socio-economic profile of the membership. Lower paid employees have sector-wide provident funds that typically provide three times annual salary on retirement, incapacity, or death. Two of the three companies contributed to industry run provident/life insurance/funeral schemes for weekly-paid worker. These companies did not therefore carry the risk that these schemes faced from HIV/AIDS with a lower socio-economic membership profile. In the third company management was in the process of agreeing to the long-standing demand of the union to transfer of the provident/insurance scheme for weekly paid workers to a new administrator.5 Medical Care The division of health provision is even more stark, better paid employees are members of medical aid schemes; lower paid employees can generally not afford to be in a medical aid scheme and rely on limited primary health care offered through company clinics and the public sector health care system.
In two of the companies the majority of salaried staff, but very few weekly paid workers, were members of the closed medical aid schemes offered by the companies. Weekly-paid staff were generally not members of the schemes because they could not afford the required payments. The economic exclusion of lower socio-economic groups from health insurance was seen to reduce the risk that HIV/AIDS could pose to these schemes. In the third company membership of a medical aid scheme was a condition of services (with the exception of existing employees who could opt out of this requirement). It was also characterized by the high use of brokered labour whose terms and conditions of employment was not the responsibility of the company.
Social Protection and HIV/AIDS Despite the relatively low risk that HIV/AIDS poses to the higher tier of social protection (because of predicted low HIV prevalence rates) and the insulation of companies from the vulnerability of the lower tier of social protection (with risk being shifted to the industry schemes in the case of risk and pensions and onto the individual and the state in the case of medical cover) it is far from likely that this is the end of the matter. Rather, it is likely that these issues will feed into wider questions of income distribution.
Social protection has been on the South African industrial relations agenda for some time and income security and health care are, essentially, secondary fronts in the struggle between labour and capital over the distribution of wealth. What has not yet happened to any significant degree is the linking of HIV/AIDS and social protection within collective bargaining. This may partly be explained by the long-term campaigns by unions to share control of their members’ savings and the difficulty of realizing that it may shift from being a strategic asset to a strategic liability. It may also be explained, in part, by the stigma around HIV and AIDS which has contributed its relatively late appearance on union agendas.
Given that the potential crises of provident funds and workers health insurance are rooted in the fundamental issue of inequality, it is likely that this situation will change.
5 The transfer appeared to involve little change in risk for the company which had assured itself that the new provident scheme was ‘well run.’ Nevertheless, management planned to have every worker sign a form agreeing to the transfer of the funds because they ‘knew they’ll come [to management] crying’ if the new scheme failed.
13 2.5 Company Responses to HIV/AIDS 2.5.1 The Response to Date The increasing visibility of HIV/AIDS – notably in the deaths of employees – appeared to be bringing about significant changes in the response of all three companies.
An escalated level of response was being considered, planned or actually in the early stages of implementation. Prior to this, activity around HIV/AIDS had been limited. Only one of the companies had an HIV/AIDS policy – drawn up in 2001 – and apart from awareness sessions around World AIDS Day very little had actually been done. As one company HR manager explained: AIDS was never a priority for us. [Ironically] We’d wear a condom on condom day, but it was never seen as a strategic imperative. Because of the up-swell in public support we’d tag along [with HIV/AIDS events], but we had so much on our plate, it wasn’t a burning issue, it wasn’t a union demand, it was never contentious, so we weren’t going to address it.
What activities had been carried out had occurred outside of any planned framework. Isolated activities had been started as early as 1998 in one company. But the individual responsible for this initiative felt that his efforts had not been supported by management and the intervention had come to a halt. Even where there was an HIV/AIDS policy the HR manager explained that there had been a ‘fragmented approach.’ This description seems over-generous given that shop-floor workers had only the vaguest recollection of any HIV/AIDS awareness sessions been run in this company. 2.5.2 Programme Components Workplace responses to HIV/AIDS involve a number of elements.
Key among these are awareness & education, peer education processes, VCT, treatment, and HIV/AIDS-related corporate social investment.
126.96.36.199 Awareness & Education Knowledge, attitudes and practice surveys are often used to assess workers’ understanding of HIV/AIDS and their response to it. This research did not include such surveys. Whether this is a limitation is questionable given the arguments put forward in this section. In depth interviews revealed that workers often did not have a clear understanding of HIV and AIDS. This was supported by a number of managers who having sat in on HIV/AIDS awareness sessions, commented on their surprise at the poor level of understanding indicated by questions put forward. While this lack of knowledge is a cause of concern, it is argued here that we need to have a better understanding of why this is the case if it is to be addressed effectively.
A lack of knowledge about HIV/AIDS can contribute to fear and stigmatization which, in turn, may result in ostracisation and discrimination. While the degree of social ostracisation of people thought to be HIV positive varied between the companies, it was not possible to clearly document any instances where individuals were discriminated against on the basis of their actual or suspected HIV status. On the other hand, it is hard to imagine that this had not occurred in contexts where managers openly acknowledged talking about people who were thought to be HIV positive behind their backs. That there was pressure to discriminate, but that this was not always carried out, was illustrated by one informant who explained that in selecting individuals for training he deliberately
- 14 ignored possible HIV status despite a perception that more senior management would like him to take this into account. He was able to resist this pressure, in part, because of the innuendo around the disease which, ironically, prevented managers from expressing themselves clearly on the matter. All three companies had, or were in the process of, running awareness and education programmes. Stress is frequently placed on the value of information in responding to HIV/AIDS. This is often based on a behaviour model (implicitly assumed or explicitly understood) which predicts that behaviour will change given correct information. Such behavioural models that regard information as necessary and sufficient for behavioural change have a number of weaknesses. These include;
- The relative weight that individuals put on outcomes, for example, how seriously a disease that may kill in a number of years is regarded by a worker who faces immediate occupation hazards;
- The need for individuals to have the power to implement behavioural change, for example women’s ability to insist on condom use within unequal relationship;
- The importance of collectively held values and norms that limit individuals’ ability to change their behaviour, for example adolescence deferring their first sexual encounter when peer norms elevate sex as a symbol of maturity.
If information on HIV/AIDS is seen, more realistically, as necessary but not sufficient for behavioural change, it becomes apparent that the provision of information alone, will not be successful in preventing HIV infection or encouraging the access of treatment. Another explanation, in addition to the weaknesses of the information-(alone)-changes-behaviour theory, for this discrepancy between knowledge and behaviour is that while individuals may know the ‘correct’ answers to questions this is not the only information that they may be ‘managing.’ Legacies of colonialism and apartheid division remain strong in South African workplaces leading to a range of ‘contextually correct’ answers to particular questions.
Box 1 illustrates this point with the case of ‘Mpho.’ What the case of Mpho illustrates is that the information provided by companies on HIV/AIDS does not fall onto virgin ground. Far from it, AIDS has been around long enough to allow complex lay or ‘folk’ theories to develop. Some of these have more than a grain of truth to them, others less. But together they already occupy the ground on which companies, waking up to the risk of HIV/AIDS in 2004, now seek to intervene. This is important to understand. To ignore this fact is to repeat – within the workplace environment – colonial-type processes of dismissing indigenously developed knowledge and devaluing those who hold them.
Blindly insisting on the scientific validity of a biologically-based explanation of AIDS will not replace the ‘wrong’ explanations of AIDS with the ‘right’ explanation; it will simply drive these views underground. They will continue to exist; hidden when the experts are present, surfacing in their absence.
15 Box 1: Mpho’s View that Spices Causes AIDS – A Well Grounded Folk Theory When Mpho, a worker, was asked what he thought caused AIDS, he replied that is was ‘spices.’ Somewhat surprised the researcher sought to confirm this view. Mpho explained that spices, such as piripiri, were now commonly available and, at R2 for a container, were being widely consumed. The availability of spices, in Mpho’s view, coincided with the arrival of HIV/AIDS. This, he put forward, was a more plausible explanation than sexual transmission given that a) many children were HIV positive and b) that the extensive campaign encouraging people to ‘condomise’ had clearly not been effective.
That spices were harmful was confirmed for Mpho by the fact that he had developed a chronic illness after he had started to consume them in quantity and that his health had improved when he removed them from his diet. Finally, he explained that his sister had dies of AIDS and he did not believe that it had been sexually transmitted (an explanation that had psychological as well as logical elements). While each aspect of Mpho’s explanation of spices as the cause of AIDS can be challenged, the more important point to note is that numerous pieces of information had, in fact, been well managed; a coherent viewpoint had been developed that was robust in a number of dimensions.
Mpho reported that when he raised this theory at an awareness session there had been a disagreement with the presenter who had explained that AIDS had come from monkeys. This explanation was again provided to Mpho when he attended the peer education session. Considerable time was spent by the presenter on the origin of AIDS and its subsequent transmission between humans. This explanation included zoonosis, HIV-types I and II, RNA, DNA, enzymes, and genetic mutation. On a number of occasions the presenter asked the group and, on one occasion specifically Mpho, if they were following the presentation.
Although it was clear, to an observer, that the account of events presented was not understood at all nobody confessed to this, although some members of the group attempted to clarify the issue by asking questions. In the afternoon break, Mpho was asked, by the researcher, what he though of the presentation. He said that he was happy to have the information on RNA and DNA – more information was good because people were dying – but he still believed that spices caused AIDS.
The view that spices causes AIDS is probably not widespread, but it was not the only alternative explanation on the cause of AIDS held by attendees who either, like Mpho, kept and maintained their views in private, or did raise their beliefs but were given short shrift by the facilitator who saw these viewpoints as undermining his biological and behavioural model; AIDS results from sexual transmission of the HIV virus, period. These theories included poverty and the breakdown of moral values as a cause of AIDS. Despite being driven into a corner on their beliefs by the presenter who utilized a range of arguments along with his status as the ‘expert,’ the proponents of these other theories remained as committed to them as Mpho.
The idea that spices causes AIDS is outlandish, but the joke is not on Mpho. It is on so called experts who cannot countenance such explanations as being well-managed theories which have been thought through, tested and developed; who assume that silence implies understanding and agreement; and who present – from the perspective of someone who has received little and poor education – ‘truth’ that is more outlandish and implausible than the ‘folk theories’ that they rubbish. 188.8.131.52 Peer Education Possible one of the most significant aspects of the increasing workplace response to HIV/AIDS is the rise of peer education.
Peer education is widely understood as an effective tool in the response against HIV/AIDS. There are limits to peer education, but among its advantages identified by
16 UNAIDS is an ability to access people infected with HIV or vulnerable to infection. This access is both physical and sociocultural (UNAIDS 1999). That is, the peer educator, as a result of his or her peer status, is a normal part of individuals’ lives and understands – through shared experience – what those individuals value, what they aspire to, and what frustrates them. HIV/AIDS peer educators have been used in a wide variety of settings where physical and sociocultural access is difficult for outsiders. Peer educators also have the advantage of being able to communicate effectively because they understand the language and patterns of communication of those who they seek to influence.
Thus, they can be seen as ‘translators’ who take technical information about HIV/AIDS and put it into forms that peers understand, making it clear how HIV/AIDS can affect them and their families.
Peer education projects have been run with sex workers, intravenous drug users, and men who have sex with men. Here the problems of access and sociocultural difference are obvious because of the often hidden and illegal nature of these activities. By contrast, the workplace is a legal and open environment in which communication should not be a problem. However peer education is just as necessary in the workplace as it is in these other environments. Workplaces, and especially South African workplaces, are deeply divided by class, race, and language. Within the context of HIV/AIDS at work, peer educators can be seen as a third channel of communication, in addition to that provided by union and management structures.
Within the responses of large companies there has been significant mobilisation of peer educators – though stronger structures appear to be associated with effective, often localised, partnership between rankand-file volunteers and managers who provide necessary resources (Innes, Dickinson & Henwood 2003).
In one of the medium-sized companies researched, management had little grasp of the concept of peer education and had no plans to facilitate it. The other two companies were in early stages of facilitating peer education as part of escalating their response to HIV/AIDS. One company had intended to interview and select appropriate ‘applicants’ from the anticipated flood of aspirant peer educators. To the surprise of management, however, there was a limited response to the call for volunteers from shop floor workers, an omission that would, of course, have seriously undermined the concept of peer education.
To an extent this was a result of the assumption that past history would be obliterated once the words ‘HIV/AIDS’ (along with ‘national crisis’ and other collective exaltations) were uttered. In contrast to this hope, a number of workers expressed their suspicion of the project and scepticism that it would lead to anything.
This of course can be overcome with a more realistic approach from management and a track record for the company’s HIV/AIDS programme. However, it is interesting to note that informants – including some from administrative positions who had responded to the call for peer educator volunteers – thought that the management call for them to volunteer amounted to an intensification of work. It was pointed out that employees who worked long overtime hours in order to take home higher wages – often out of necessity rather than choice – were hardly likely to volunteer to take on an extra responsibility for the company.
This response most probably stemmed, at least in part, from management’s control of the HIV/AIDS response process. It was not a joint call resulting from a collective agreement between management and worker representatives who had drawn up the company’s HIV/AIDS programme.
This is not to say that a joint management-union plan would have resulted in the hoped for flood of selfless volunteers (though it would have helped). Rather, it is likely that a genuinely ‘co-created’ response to HIV/AIDS would have taken into account the sacrifices required of an active peer
17 educator and put in place measures to meet potential volunteers part way – by, for example, giving some time off work for peer educator activities on condition that this was properly accounted for. Such ‘concessions’ should not be seen as undermining the purity of volunteerism, but, rather, reflecting the fact that any effective and sustainable initiative require a minimum level of resources.
That this was not attempted points to the danger of managers, even well informed managers, selecting ‘best practice’ aspects of responses to HIV/AIDS, such as peer education, while choosing to downplay accompanying recommendations that, for example, all stakeholder should be integrally involved from the beginning of the process.
184.108.40.206 Voluntary Counselling and Testing (VCT) and Treatment Relatively little had been done by the companies in terms of getting workers to find out their HIV status and, if positive, access antiretroviral drug treatment. The most extensive VCT activity had occurred in one company where each World AIDS Day for the previous three years an event had been organised with the hope that people would be encouraged to go to the company clinic for voluntary testing and counseling (VCT). The first year they had an awareness session, but there was negligible VCT uptake. The following year they tried splitting the workforce into different language groups for the session, again negligible VCT uptake.
The third year they had brought in an industrial theatre company, still no VCT and they were wondering what they should do next. During this escalation of activity there had been no overall assessment of how VCT uptake could be promoted. Thus, for example, peer education had not been considered and the concept was poorly understood by those managers responsible for the interventions. Moreover, the suitability of the company clinic for VCT had never been assessed though it was patently inadequate.
The other two companies had not attempted any organised promotion of VCT and views were mixed about how many workers would take up the opportunity of establishing their HIV status. Doubts in this regard were generally based on workers fears around confidentiality, the stigmatized nature of the disease, and a lack of available treatment. One of these companies hoped to move towards a VCT campaign once a peer educator structure was in place which would be able to raise awareness. In fact a small amount of VCT had taken place in all the companies though the occupational nurses’ clinics. Facilities available for this service were far from ideal.
All three Sisters felt that they did not have enough time to carry out their occupational and primary health care responsibilities, let alone provide HIV/AIDS counseling, given the time they had available. At one clinic the Sister explained how she had once had to spend an hour of the two-hour surgery counseling a workers whose result had been positive. She felt it was not feasible to continue this service. Another nurse explained that she ‘took a chance’ with two employees since she had not received HIV/AIDS counselor training. Fortunately, both results had come back negative.
Unknown to management some workers were on anti-retroviral drug treatment, paid for by their medical aid, which the industrial nurses helped administer. All of the companies had workers without medical aid cover, but none had plans for the provision of antiretroviral drugs. For the one company hoping to introduce a VCT campaign this presented a problem given recognition that VCT uptake would be negatively affected if they could not offer anti-retroviral drugs should people be HIV-positive. However, management responsible for the HIV/AIDS programme was acutely aware that they would not get the go-ahead from the company for such provision at this stage.
Only if they
18 were able to establish the need for such treatment – i.e. with people testing – would it be likely that senior management could be persuaded to take this step. 220.127.116.11 Corporate Social Responsibility: Glossy and Safe or Local and Difficult? The medium sized companies researched practice corporate social responsibility (CSR).6 CSR implies recognition of social need and that the company is able to assist. There are also other benefits, including the achievement of status and satisfaction in donating to ‘worthy causes’ and the image that the company can build and maintain as a result of publicizing CSR activities.
Given the scale of the HIV/AIDS epidemic, high levels of poverty, and the inadequate resources of the state, there is clearly an important role for CSR in relation to HIV/AIDS outside the workplace. What is emerging within companies that respond to HIV/AIDS is a complex interface between HIV/AIDS-related CSR and the HIV/AIDS committees that are being established and which tend to be concerned with the impact of HIV/AIDS beyond the factory gates. This concern is often strong and results from a number of factors. First, there is a degree of self-selection onto HIV/AIDS committees with socially concerned individual often putting themselves forward or willing to accept nomination.
Second, such committees tend to have representation across a range of stakeholders. Third, there are clear reasons why a response to HIV/AIDS that is limited to the workplace is unlikely to be successful.7 This presents company HIV/AIDS committees with the difficult problem of balancing their impact within the workforce with the potentially unlimited task of responding to drivers of the epidemic such as poverty and inequality beyond the workplace. In attempting the difficult and genuine dilemma of achieving such a balance a fault line emerges between those who believe the company’s CSR efforts in relation to HIV/AIDS should be linked as directly as possible to its workforce and those who see do not see this need.
Those arguing for direct linkage point out that, in fact, poverty is widespread among workers families and communities and that HIV/AIDS is further corroding the already weak social fabric of the townships where workers live. While they are not opposed in principle to the company providing high-profile donations to well-known but distant HIV/AIDS projects, they point out that there are more pressing priorities and often more desperate need on the company’s doorstep. Such a view is, not surprisingly, expressed by workers and shop stewards, but it is also found among administrative workers and some managers who have either bridged existing social distance in some way or who recognised the logic of the arguments being put forward.
Those who favoured more high-profile CSR – usually beyond the immediate communities from which their employees were drawn – appeared to do so more out of inertia and conflicting pressures then direct opposition to the reasons put forward from those favouring CSR in local townships. Companies expect to get some publicity for their CSR. Such publicity is easier and safer when handing over a cheque to, for example, a high-profile AIDS orphanage, than if CSR involves difficult and complex process of attempting to work with locally-based community organizations. It is also possible that such a debate may be threatening to some managers who have previously seen 6 The term ‘corporate social investment’ (CSI) is also widely used.
While the terminology is claimed, by some, to be of significance in practice the terms are interchangeable.
7 The most obvious of these is that the primary transmission route is sex, an activity that largely occurs outside of the workplace. Treatment programmes will also be compromised if not extended beyond employees, for example, company provision of anti-retroviral drugs to HIV-positive employees is unlikely to be successful if spouses and children (who may well also be HIV positive) are not included in such programmes.