HIV/AIDS in Manufacturing and Construction Companies in Ekurhuleni - David Dickinson Wits Business School And Marije Versteeg Madibeng Centre ...
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HIV/AIDS in Manufacturing and Construction
Companies in Ekurhuleni
David Dickinson (Wits Business School)
And
Marije Versteeg (Madibeng Centre for Research)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.
2these 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 company-
based 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.
3Contents
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
2.5.2.1 Awareness & Education
2.5.2.2 Peer Education
2.5.2.3 Voluntary Counselling and Testing (VCT) and Treatment
2.5.2.4 Corporate Social Responsibility: Glossy and Safe or Local and Difficult?
2.5.3 Health Resources
2.5.3.1 Industrial nurses
2.5.3.2 Public Sector Health Provision
2.5.3.3 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
43.6.1 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
5Glossary 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
6Section 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.
7Section 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.
8In 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.
92.4.2 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; higher-
paid 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.
10Table 2: The Two-tear Provision of Social Protection in the Manufacturing Sector
Social Mechanism(s) General two-tier provision structure
Protection
Lower-Income Employees Higher-Income Employees
Element
1. Private Insurance: employers and employees contributions Low-paid workers join provident schemes High-paid workers join pension schemes
• Payment in the event of death or disability while of
working age (risk component) • Provides lump sum payment for incapacity • Provides pension (for beneficiaries in the
• Payment upon retirement (retirement component) or retirement, generally three times annual event of risk cover, for member in the
Risk and • May include other insurance elements (e.g. funeral cover) salary event of retirement)
retirement • Schemes are run on an industry basis under • Schemes are run on a company basis under
benefits the control of a joint union/employer control of joint management/employee
representative body representative body
2. State pension provision/disability grant • Universal state provision (low level). No
risk cover for pre-retirement age death
1. Medical aid: employers and employees contributions Lower paid-workers cannot afford medical aid Higher-paid workers join medical aid schemes
• Payment for medical costs for member and dependents contributions and rely on company-provided
some co-payments depending on scheme rules primary health provision and state health care. • Employee and families able to access
• Provision of anti-retroviral drugs and associated costs For employees accessing state health care required health care as required. For
through disease management schemes for most medical requires sick leave. employees this minimises need for sick
aid programmes leave.
• Other than for basic problems employees • Employees and family members generally
2. Company-based primary health care: employer pays access public health care system. able to access antiretroviral drugs via
• Generally linked to occupational health services disease management programmes.
• Limited in provision
Medical • Some large companies now providing anti-retroviral
care 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
11Risk 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.
122.5 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.
2.5.2.1 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
13ignored 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.
14Box 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.
2.5.2.1 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
15UNAIDS 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 rank-
and-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
16educator 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.
2.5.2.3 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
17were 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.
2.5.2.4 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.
18company CSR activities as a matter of managerial prerogative and a provider of status in the circles
of their choice.
Thus the establishment of HIV/AIDS committees within companies provides a forum in which the
question of companies’ role within wider society is raised. Such debates may be extremely valuable,
if they are allowed to run and remain focused on finding practical CSR activity within the grasp of
companies. If this is not the case – and in the absence of any statutory basis for such committees –
there is a danger that individuals who feel threatened by the questions raised will marginalize, rig,
or close down such groups.
2.5.3 Health Resources
A range of health resources are available within the context of workplace HIV/AIDS programmes.
The most significant of these are industrial nurses, public sector health facilities, and – largely for
African employees – traditional healers.
2.5.3.1 Industrial Nurses
Industrial nurses, generally trained in both occupational (Health & Safety) and primary health care,
form a widespread but low-profile element of the workplace. Despite their relatively small size all
three companies researched had, on a part-time basis, an industrial nurse (all female) with a surgery
based on the company premises.
One clear motivation for the introduction or greater use of industrial nurses by all three companies
was increased concern over occupational health and the possible liability on the part of the company
in this regard. However, the regular presence of a health professional in a company clearly provides
an important resource for HIV/AIDS programmes. This could include assisting in monitoring and
treatment of HIV-positive employees, identifying and counseling workers who showed symptoms
that could be HIV related, provision of VCT, assistance in wellness programmes, and general
education and awareness on HIV/AIDS. To some extent ‘the Sisters’ in these companies were
carrying out these activities. But they had to do so from positions that were not always easy to
maintain given limited resources and only weak referral routes to further treatment and care.
As professionals, industrial nurses are not accountable to a line manager within the company.
However, the company does, in fact, dictate what and how they do their jobs this is not through
direct instructions but the allocation of resources. Rather, the way industrial nurses carry out their
work on a day-to-day basis is governed by professional standards, their relationship with the
company doctor (a generally remote figure providing services to the company for only a few hours
a week), and, where the industrial nurse is an outsourced employee, to their actual employer.8
Despite this professionalism it was not uncommon for industrial nurses to find themselves under
pressure from management who wanted to know, or confirm, if employees were HIV positive. This
clearly placed them in a difficult situation and their refusal – in two of the companies researched –
to provide this information9 appeared to lead to their marginalization by management. Several
8
This set of relationships is typical only for the size of companies researched for this project. Very small companies
typically provide no on-site health provision. Large companies have more extensive occupational and primary health
care structures with different dynamics.
9
The need to refuse such requests was sometimes learned the hard way. One Sister recounted that she once informed an
HIV-positive employees’ supervisor that the reason that she wanted to see the employee was ‘confidential.’ When, later
19managers explained to the researcher that an interview with the Sister would not be of much value
because she had little information on HIV/AIDS. This proved not to be the case, especially when
the Sisters were African and socially closer to shop floor workers. They knew of a number of HIV-
positive employees and in one case the Sister was assisting in the provision of antiretroviral drugs
for employees, something about which management was unaware. This confusion on the part of
management, between Sisters’ professional obligations and their actual knowledge of the impact
HIV/AIDS was having on the company, may explain why these nurses were not included in the
companies’ plans for upgrading their responses to HIV/AIDS.
Another reason for this exclusion of industrial nurses from HIV/AIDS planning and structures was
the sometimes tense (triangular) employment relationship that existed. In all three companies the
industrial nurse was outsourced – generally a fairly new development. In all three companies the
nurses felt that they did not have adequate time or resources to carry out their responsibilities in the
way they felt was professionally required and there were ongoing discussions with management
about this. In this context it would be unlikely that management would ask them to take on an extra
dimension of work.10
As outsourced employees they are clearly in a weaker position than when, as has historically been
the case, the Sister was an employee of the company. Should nurses push too hard, management can
request a replacement – an action that raises less difficulties than attempting to remove a Sister on
the company payroll who is raising uncomfortable issue which can be backed up with arguments
around professional standards. Consequently the Sisters had to make compromises in what they
could provide, given that managerial priority was occupational health; it was primary health care
provision that suffered. As one Sister explained:
I don’t have enough time provide occupational and primary health care services. Where
I can steal time is with the primary care. If the problem is minor I don’t dwell on it. I
give the medication to the patient that will assist them and that’s it. But primary health
care shouldn’t be about that. We should examine the whole patient [i.e. talk about their
lifestyle and general health that may be connected to the immediate problem]. We’re not
doing that.
Within the context of an HIV/AIDS epidemic this limitation on industrial nurses’ work is
significant. Dealing with possibly HIV-positive patients is time consuming as is any attempt to be
pro-active in the promotion of VCT. If industrial nurses are struggling to complete their duties in
regard to occupational health requirements and dealing with employees knocking on their doors
during clinic hours, their ability to make a contribution to a company response to HIV/AIDS is,
despite their uniquely qualified position, restricted.
2.5.3.2 Public Sector Health Provision
In their work industrial nurses must cope with limited medical resources. This, of course, is always
going to be the case as they form only part of a much bigger health care system and there are limits
to what they can and should provide in their clinics. The employees who most heavily depend on
in the day she went into the office of the MD on a completely different matter, the MD, who was several reporting
levels above the supervisor, asked for confirmation that the employee was HIV positive.
10
Another implication of industrial nurses being outsourced is the likely shorter time they will spend in one workplace.
Two of the Sisters interviewed had been at ‘their’ company for less than a year. A number of workers indicated that
they didn’t ‘know the new Sister.’ Such unfamiliarity is likely to be significant in regard to HIV/AIDS when a high
level of trust is required before people will risk divulging their status or concerns.
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