Who is Nursing Them? It is Us

Neoliberalism, HIV/AIDS, and the Occupational Health and Safety of South African Public Sector Nurses

Jennifer Zelnick, Charles Levenstein, Robert Forrant, John Wooding, Jennifer R. Zelnick

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9780895033277
• eBook ISBN: 9781351840699
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book explores the impacts of HIV/AIDS and neoliberal globalization on the occupational health of public sector hospital nurses in KwaZulu-Natal, South Africa. The story of South African public sector nurses provides multiple perspectives on the HIV/AIDS epidemic-for a workforce that played a role in the struggle against apartheid, women who deal with the burden of HIV/AIDS care at work and in the community, and a constituency of the new South African democracy that is working on the frontlines of the HIV/AIDS epidemic. Through case studies of three provincial hospitals in KwaZulu-Natal, set against a historical backdrop, this book tells the story of the HIV/AIDS epidemic in the post-apartheid period.

CHAPTER 1

Globalization and Health in
sub-Saharan Africa

The story of the occupational health of nurses in KZN, South Africa, needs to be understood in terms of the global forces that impinge on nurses’ care for people with HIV/AIDS. The goal of this book is to treat a complex subject in a complex manner. Academic study of and debate about the nature of neoliberal globalization; theories of the work environment; brain drain and the global nursing shortage; the African and South African HIV/AIDS epidemic; and nurses, HIV/AIDS and occupational health are important to developing a rich context. The coverage is not meant to be exhaustive; rather it highlights aspects of the debate that are most salient to this project.

Neoliberal Globalization

Ideology or Legitimate Economic Development Strategy?

Neoliberal globalization, understood as an attempt by an elite group to organize and manage a global free trade/free enterprise economy, makes privatization and monetarism the cornerstones of health policy for developed and developing countries. This is the current context for health-sector development.

Neoliberal globalization refers to the global extension of “free market” principles, and in theory, the integration into one world market (Tabb, 2001). Its proponents have argued that globalization will result in an upward convergence between wages and standards of living between developed and developing countries. Neoliberal policies center on the claim that a free market, through competition and consumer demands, will result in the greatest efficiencies for producing goods and services alike. Basic policy prescriptions aim at reducing regulations on capital and production, privatization, and restraint in state spending (McMichael, 2000). The economic theory supporting neoliberal policy is most associated with Milton Friedman of the University of Chicago (Friedman, 1962), and the driving idea is that the unimpeded market will provide efficiency and maximum profit, and that this course of development will trickle down throughout a society and provide the best distribution of wealth. In the developing world, the International Monetary Fund (IMF), the World Bank, and the World Trade Organization (WTO) have historically been at the forefront of developing and enforcing neoliberal policy packages, notably through Structural Adjustment Programmes and IMF loan conditionalities beginning in the 1980s.

Critics of neoliberal globalization object to policies aimed at expanding the global free market and the claim that the market will be sufficient to solve many social and economic problems. An underlying criticism of neoliberal globalization is that it is an ideology propagated by an elite class masked as economic development theory. This view has been developed critically by an analysis of power in the post-Cold War period, and empirically by pinpointing how evidence used to evaluate the success of neoliberal policies is skewed or ignored.

A relevant example for African postcolonial development is the examination of the case of the so-called Asian Tigers, developed by Arrighi (2002). South Korea’s swift economic development is often held up by the World Bank, IMF, WTO, and academic supporters as the model of how neoliberal policies lead to rapid export-based economic growth. The Asian Tiger “model” fails to account for the fact that in actuality, these economies were highly protected through authoritarian, often repressive governments and supported with international preferences. The argument for reduced state involvement and the free market—centerpieces of neoliberal policy—is therefore not supported through this example. Arrighi then offers an alternative explanation that compares development in certain African and Asian countries over specific time periods, which supports his contention that limited opportunities and global conditions were the most important factors in the bifurcation of success in the economic growth of developing countries in different regions of the world.

The Municipal Services Project (MSP) is a research, policy, and education initiative begun in 2000 to examine the restructuring of municipal services in southern Africa. The project’s central interests are “the impacts of decentralization, privatization, cost recovery and community participation on the delivery of basic services to the rural and urban poor, and how these reforms impact on public, industrial and mental health” (Municipal Services Project [MSP], 2008). McDonald (2004) describes how the sale of state assets to private firms, and subsequent privatization and partial privatization of water and electricity in South Africa, have not reduced the cost of services, increased their availability, or resulted in economic gains for municipalities, though these outcomes were the explicit claims motivating privatization. Through case studies such as privatization of water services in the Western Cape (South Africa) and Buenos Aires (Argentina), and electricity services in Soweto (Gauteng, South Africa), the MSP builds an empirical base for criticizing the specific tactics of neoliberal policy.

Rowthorn and Kozul-Wright (1998) argue that economic data do not bear the claims of neoliberalism’s proponents that domestic policy is irrelevant to development, and that economic growth can hinge on outward-directed policy. They confirm that domestic policy, including industrial policy, continues to be a key to economic and social development in the developing world, despite the shift in policy trends from “developmentalism” to “globalism” (McMichael, 2000). Mkandawire and Soludo (1999) make the same arguments from the African perspective, noting that state policies and social spending in African counties had made positive impacts before SAPs were introduced. These observations are part of a critical analysis of the harm done when national sovereignty over policymaking is relinquished to global economic interests.

A hallmark of the criticism of neoliberal globalization is that so many people are left out of its benefits and decision-making processes. Navarro (2004) argues that class power and an alliance of elite interests within and between countries is a defining characteristic of this type globalization.

What now passes as globalization is a specific type of internationalization of capital, labor, and knowledge, characterized by an unrestrained and unregulated search for profits and greatly enhanced by the public policies initiated by the governments of President Reagan and Prime Minister Thatcher and continued by their successors . . . neoliberalism and globalization are the instruments of class domination. (p. 222)

His descriptions of globalization as an ideological projection by a group of self-interested leaders is echoed by McMichael’s (2000) description of the “Globalization project” as

An emerging vision of the world and its resources as a globally organized and managed free trade/free enterprise economy pursued by a largely unaccountable political and economic elite. (p. 354)

Translating this to the postapartheid South African experience, Bond (2000) describes how elites within South Africa’s ANC-led government pushed the adoption of neoliberal policies and betrayed the hopes and loyalties of poor and working class South Africans. He analyzes the ANC adoption of neoliberal policies in terms of the formation of a new elite class of black South Africans, formally of the liberation movement, and terms the new terrain in South Africa “class apartheid.”

Neoliberal policy trends have also been at the center of debate over health policy. In the 1980s the Reagan government in the United States and the Thatcher government in Britain advocated for commodification and privatization of health care services (Navarro, 2004). This has taken many forms, and no part of the world has been immune to the focus on cost-effectiveness as a key criterion for health systems. Navarro examines how the World Health Organization (WHO), the largest international body devoted to international public health, reproduces the discourse of the market in health care based on the private U.S. model, despite evidence to the contrary that shows how market-based health policies have resulted in millions of uninsured in the United States, and the dissatisfaction of the vast majority of people with their health care. The WHO, along with the World Bank and IMF, has played a key role in exporting these policies to the developing world beginning in the 1980s (Turshen, 1999). Turshen carefully documents the impacts of privatization policies on health services in Africa, concluding that they have resulted in an overall disinvestment in health.

The HIV/AIDS epidemic exploded in southern Africa during the period of globalization, structural adjustment programs, and neoliberal reforms. Just a few decades prior, many African countries newly independent from colonial rule, held out the promise of better life and health. Indeed, during the late 1950s and the 1960s great improvements were made in such things as life expectancy and infant mortality. In the 1970s state-led national development was replaced by the push for participation in the global economy (McMichael, 2000). Beginning in the 1980s (SAPs), brought about by neoliberal globalization, destroyed the capacity of African countries to determine their own social spending, and thus to build working health systems (Gloyd, 2004; Mkandawire & Soludo, 1999; Turshen 1999). The adoption of neoliberal economic and social policies had grave consequences for public health and health services in southern African countries and is one key to understanding the explosion of the HIV/AIDS epidemic in sub-Saharan Africa. The withering of the public health infrastructure had profound consequences for frontline health care workers, especially nurses.

Neoliberalism¹ came to Africa via the World Bank (WB) and International Monetary Fund (IMF). Structural Adjustment Programs introduced in the 1980s in the context of the African “Debt Crisis” demanded policy reforms that, although aimed primarily at economic growth, affected all areas of development (Mkandawire & Soludo, 1999). Because within the orthodoxy of neoliberalism the free market provides the most efficient and productive way to fund and deliver social goods, economic growth was given a central position in all policy areas, including health and education. Since the neoliberal view sees much of the public sector as a distortion of the free market, this set of policies amounted to a specific attack on publicly financed and supplied social goods like education and health care.

Health and Development in sub-Saharan Africa

Many of the SSA countries achieved independence from colonial rule in the 1960s and 1970s. The ideals of liberal democracy and human rights, refashioned by Africans from the traditions of colonizers and then used against them during independence struggles, placed the language of rights and equality at the center of independence struggles (McMichael, 2000). The international black power movement and the socialist example fed the formation of fledgling nation states. Despite ethnic differences and borders drawn by colonists, independence movements were intensely nationalistic. Bond (2001) comments on how nationalist movements used democratic principles as their rallying points:

The language of the nationalist movement was the language of democracy, as is clear from: I Speak of Freedom (Nyerere), Without Bitterness (Orizu), Facing Mount Kenya (Kenyatta), Not Yet Uhuru (Odinga), Freedom and Development (Nyerere), African Socialism (Senghor), and The Wretched of the Earth (Fanon). It denounced the violation of dignity of the colonized, the denial of basic rights, the political disenfranchisement of the colonized, racial discrimination, lack of equal opportunity and equal access, and economic exploitation of the colonized. The people were mobilized according to these grievances and expectations of a more democratic dispensation. (p. 45)

Independence meant that SSA states could begin to define their own development trajectory. Import Substitution Industrialization² (ISI) was adopted in sub-Saharan African countries to compensate for the colonial division of labor, which had relegated them to producers of primary commodity exports (Mkandawire & Soludo, 1999). This policy direction was predicated on terms of trade decline for primary commodity exporters. ISI was supported by policies such as exchange-rate manipulation, import tariffs, and subsidization of industry that were intended to protect fledgling industries. ISI was the “economic orthodoxy” in the postwar Latin America (McMichael, 2000), and it was widely followed in independent African states.

At least a portion of the revenues derived from import-substitution manufacturing was invested in the nation. Even with high levels of corruption, most nations began a vigorous program of social spending on such things as health care and education (Schoepf, Schoepf, & Millen, 2000). In addition, states were encouraged by the IMF and the WB to borrow billions for major infrastructure programs like dams, hydroelectric power plants, highways, and airports (Bond, 2001).

SSA countries made substantial gains in this period. In some countries primary school enrollment increased by as much as 25%. The industrialization process, however incomplete, added infrastructure and developed workforce skills in management and administration (Mkandawire & Soludo, 1999). Health systems were expanded (Turshen, 1999). The improved HDI ranking of SSA countries in this period reflects these improvements (Arrighi, 2002).

The approach that African countries took to development was a mirror of the approach to development in first- and second-world countries across differences in political systems. Industrialization was a key policy area for securing economic independence and political legitimacy (McMichael, 2000). Political legitimacy came as a result of meeting social needs for education, health, and basic services.

Development efforts had transnational and international aspects. African countries made strides to band together with other developing countries to change the parameters of world economic order, examine the social needs of citizens, and address terms of trade imbalances (Arrighi, 2002). In 1967 the group of 77 (G77) was formed in an effort to create one voice for third world nations at the United Nations Conference for Trade and Development (UNCTAD) in Algiers (Tabb, 2001). The New International Economic Order (NIEO) was developed as an instrument to, in the words of the late Tanzanian president Julius K. Nyerere, “complete the liberation of third world countries from external domination” (Nyerere, 1979). The Organization of African Unity (OAU) was formed in 1963 to support liberation struggles in Africa. By the 1970s its mission had come to include mutual support for postindependence development goals based on unity and solidarity within the region (Arrighi, 2002).

Health System Development

Health system development in the independence era occurred atop the history of colonialism (Gish, 2004). Colonization and the slave trade brought diseases and social disruption to Africa. As the colonies produced food that replaced food production of working-class Europeans turned industrial laborers, the amount of food produced for local consumption fell, causing hunger and malnourishment. The Western medical approach to health was imported by colonists, but was not widely available for ailing Africans. At the same time, traditional systems, practitioners, and indigenous understanding of health were interrupted. Over time, systems emerged that embodied the dictates and ideology of colonialism. This meant first-rate Western medicine for whites, public health measures to stop the spread of disease to whites (but not to promote the health of Africans), and care for black laborers insofar as it supported economic interests (Gish, 2004).

Colonial health systems were centered on the urban hospital, located where the largest nonnative populations lived (Turshen, 1999). The government hospital was also essential to colonial rule and often operated as an extension of the military. Rural dispensaries, typically run by missionaries, offered drugs and basic maternity services. Investment in the health of native populations was marginal (Banerji, 2004; Gish, 2004). After independence, many African governments extended these inherited health services, and did not change the basic focus of the Western model (Schoepf et al., 2000). This meant that weaknesses in addressing public health, limited rural access, and lack of community input were often reproduced (Gish, 2004):

Often leaders of newly independent countries, and, more particularly, the medical leadership, did not question the essential character of the health services they had inherited. Instead, they aspired to spread these services to the whole of the population. The new services were to be “high standard,” as defined by the medical elite, and at the same time serve the needs of the whole population. More often than not though, it was the prestigious hospital plan that was approved and built, and no...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgments
• Introduction: Understanding a Public Health Crisis from a Work Environment Perspective
• Chapter 1. Globalization and Health in sub-Saharan Africa
• Chapter 2. Neoliberalism in Postapartheid South Africa and the HIV/AIDS Epidemic
• Chapter 3. The Work Environment of Nurses
• Chapter 4. Case Study Setting: Three Public Hospitals in KwaZulu-Natal, South Africa
• Chapter 5. Staffing, Occupational Health, and HIV/AIDS
• Chapter 6. Nurses Speak
• Chapter 7. Discussion—Breathing Life into Policy: Toward a Labor/Work Environment Perspective on a Global Public Health Crisis
• Appendix: Group Interview Results Summary
• References
• Index