|Women Encounter Technology: Changing Patterns of Employment in the Third World (UNU, 1995, 356 pages)|
|13. Gender perspectives on health and safety in information processing|
Groups of workers who have suffered from conditions attributed to using new technology have brought the issues into public and political forums by their attempts to gain recognition and compensation for their conditions. An article in the International Labour Review accurately reports:
VDUs have aroused intense debate and often controversy over the implications for workers, particularly the risks to health. Although relatively few countries have passed laws or regulations referring specifically to VDUs, several have recommended codes of practice or guidelines for their use. These cover a variety of issues, such as advance notice, consultation and negotiation procedures with workers or their represent atives, training, job design and job security, rest breaks, maximum VDU use, protection during pregnancy, eye care and machine and workstation specifications.
(Di Martino and Wirth, 1990: p. 542)
This gives the impression that there is general agreement in 'several' countries, recognizing the health risks associated with working with computers and related technology, and that there are agreed procedures about prevention and worker protection. It might lead the reader to suppose that these health risks have been defined as industrial injuries for which insured and protected workers are entitled to some degree of compensation.
The reality is quite different. There is an enormous amount of controversy over the medical and legal issues relating to information technology and health risks. The lack of agreement has meant that recent legislation and recommendations within the European Union (EU), have provided much less worker protection than had been expected. It will be worthwhile to survey the medical controversies, and the differing legislative and political debates over repetitive strain injury (RSI) in Australia and the UK. This information will provide a basis for an analysis of the health and safety risks faced by new technology workers in developing countries, from a gender perspective.
Health risks and computer work
Although there is no medical and legal agreement of the degree of risk and vulnerability to various health conditions, the literature has established five types of health hazards which have been attributed to work with computers, and more specifically to the work situation of inputting or manipulating text or data using a visual display unit (VDU) or visual display terminal (VDT):4
1 Musculoskeletal; this includes a range of named disorders of the neck, upper limbs, shoulders and back, including tenosynovitis, tendinitis, peritendinitis, bursitis, epicondylitis, carpal tunnel syndrome, dupuytren's contracture, writers' cramp, ganglions, and cervicobrachial disorders (Putz-Anderson, 1988(a); Huws, 1987). These conditions are not identical with the list of thirty separate diseases in the International Classification of Disease Codes, which includes carpal tunnel syndrome, cervicobrachial syndrome, tenosynovitis, and ganglions (cysts), but which makes no mention of repetitive strain injury (Putz-Anderson, 1988(b): p. 601).
2 Deterioration of and problems with visual capacity, including eyestrain and fatigue, loss of focus and mobility, reduction in capacity to dilate pupils. and cataracts (ibid.). The symptoms linked to eye strain include blurred and double vision, irritability, headaches and migraines, nausea, and discomfort with contact lenses (DeMatteo, 1985).
3 Stress and fatigue; symptoms include short-term problems of fatigue, irritability, depression, headaches, migraine, insomnia, menstrual problems, and accidents, and long-term problems of heart disease, high blood pressure, depression, anxiety, dermatitis, ulcers and fertility problems.
4 Skin complaints including rosacea, acne, dermatitis, telangiectases, pustolosis, urticaria, ostitis and other unspecified changes (ibid.:, and Berg et al., 1990).
5 Reproductive hazards; miscarriages, congenital deformities and fertility problems associated with stress and with emissions of ionising and nonionising radiation from cathode ray tubes fitted in now obsolete computer monitors (Labour Research, 1984; DeMatteo, 1985; Brandt and Nielsen, 1990).
The literature on reproductive hazards remains deeply contested, and is based on reported or observed clusters of adverse pregnancy outcomes including miscarriages, stillbirths and abnormalities. The 1992 UK Health and Safety Regulations state that:
There has been considerable public concern among some groups of visual display unit workers in particular due to electromagnetic radiation. Many scientific studies have been carried out but taken as a whole they do not show any link between miscarriages or birth defects and working with VDUs.
(HSE, 1992: pp. 42-43)
We will confine our discussion to the first category, which has been labelled as RSI (repetitive strain injury), since these injuries can lead to a total inability to carry out many tasks (R.M. Pearson, 1990). It is worth noting however that figures issued by the Data Management Association in North America indicate that eyestrain is in fact the most commonly experienced health problem of VDU workers (Bodek, 1987). This finding is supported by data from Malaysia (Ng and Othman, 1991) and Japan (Shiga, 1987).
'If I can't see it doesn't exist': medical controversies over computer-related repetitive strain injuries
Musculoskeletal disorders cause the most severe incapacity amongst sufferers. Although back and shoulder ache feature very frequently amongst surveys of work-related problems of computer clerical workers, the term RSI applies particularly to problems with hands and wrists, and necks. The range of musculo-skeletal conditions which have been reported illustrates that the precise medical diagnosis can fall within a wide range of conditions, and of course can comprise a composite of two or more of these conditions (Bammer, 1990). Despite the frequency with which symptoms are reported amongst office workers, medical opinion remains divided over:
1. whether a term such as RSI has any meaning or usefulness;
2. the medical diagnosis of the symptoms;
3. whether there is in fact a physiological basis, rather than a psychological basis, for the reported symptoms; and
4. whether there is any evidence of causation which would link particular kinds of work with these symptoms.
It is beyond the scope of this paper to present an exhaustive review of the medical evidence and disputes which swirl around this issue, but it is useful to present some of the arguments, since the controversy over the existence and causation of RSI is important in contextualising the link between the gender bias of the new work categories and work organization associated with computers and attitudes to the health and safety of workers in LDCs.
What do we mean by repetitive strain injury? (It depends on who we are.)
In spite of the ubiquity of the symptoms of RSI there is no agreement about definitions or terminology. In Australia, the conditions of tenosynovitis, tendinitis and bursitis have been recorded as compensatable industrial conditions since the 1960s, and 'from the end of the 1970s newly established workers' health centres began to use the term 'teno' to cover all of the repetition injuries they were finding amongst their predominantly blue collar clientele' (Hopkins, 1990: p. 367, emphasis added). When the incidence spread to the newly established and expanding white collar segment of the workforce, the term 'repetition injury' began to be widely used by organizations such as the Australian Public Service Association, the National Health and Medical Research Council and the National Occupational Health and Safety Commission. This term was extensively adopted by the media and by many doctors who were not specialists but were required to respond to the increasing number of people presenting with symptoms consistent with what was widely understood by the term.
In the UK however, whilst the term 'repetitive strain injury' is widely used by the media, by sufferers (who have formed an RSI association), and by some doctors and specialists, it has been studiously avoided by the Health and Safety Executive who prefer to refer to 'work-related upper limb disorders. These range from temporary fatigue or soreness in the limb to chronic soft tissue disorders like peritendinitis or carpal tunnel syndrome. Some keyboard operators have suffered occupational cramp' (HSE, 1992: p. 41).
In the United States the term 'cumulative trauma disorder (CTD) has been used within the occupational health and safety literature. This is a much less transparent term for the general public. Although some agencies do use what is known as the Australian term (repetition strain injury), a lot of occupational medical literature still uses the generic 'musculo-skeletal problems', which is totally neutral in terms of causation' (Putz-Anderson, 1988b). In the USA there is not - as yet - a widely accepted acronym. It has been claimed that the absence of an acronym contributes to the lower rate of recognition and discussion of the problem in that country.
In Sweden, where discussion and remedial policy is well advanced, the terms adopted are ergonomically-related injuries (ERI) or occupational cervicobrachial disorder (OCD), collectively referred to as work-related musculoskeletal disorders. These terms reflect the consensus that occupational labour processes are implicated, but place the emphasis on ergonomic rather than other factors.
These terms are themselves being challenged or refined, not least by medical specialists who are engaged in a fierce dispute about the medical validity of the terminology utilized. Recent (equally disputed) additions to the nomenclature are 'overuse syndrome' (Fry, 1993) and 'refractory cervicobrachial pain' or RCBP (Quintner and Elvey, 1991, cited in Cohen et al., 1992).
There is disagreement as to the meaning of the terms utilized to describe the symptomology (which is not itself disputed), with much specialist medical opinion decrying the 'unscientific' nature of the generic terms employed. Without wishing to enter into this acrimonious dispute, the following extracts convey some of the flavour of the discourse:
Conventional medicine is not prepared to accept that a physical injury or disease process occurred in an upper limb, or indeed elsewhere, unless there are convincing and reproducible physical signs. The accepted signs of an injury and associated healing are those of tenderness, loss of function and associated histological findings of inflammation . . . until such independent support is forthcoming, the overuse concept should remain an eccentric and unproven hypothesis.
(Semple, 1993: p.25)
The self-generating term RSI is misleading for there is no scientific evidence proving that repetitive work causes either tissue strain or injury.... The scientific basis of modern medicine demands that disease is caused by a pathological process which, if not identifiable, has a rational hypothesis, thus enabling formulation and designation of appropriate management.... RSI now bears the hall mark of a sociopolitical phenomenon, rather than a medical condition, which on historical precedent, will decline when this basis of RSI is generally accepted.
(Ireland, 1988: p. 5)
Medical explanations of RSI: the doctors' dilemmas
The dispute as to whether the symptoms known as RSI are related to physical injuries, and if so of which type, continues without any sign of a resolution. The position of Semple, that without discernible and replicable physiological signs the patients' symptoms should be dismissed, represents one extreme of the debate. But amongst those who accept that the symptoms have a physiological cause, opinion is widely divided as to whether the explanatory physiological base lies in damage and malfunction of the central or peripheral nervous system (Quintner and Elvey, 1991; Cohen et al., 1992), or in muscle overuse (Fry, 1993), and whether its treatment belongs within the specialism of rheumatology, orthopaedic surgery, physiotherapy, or some combination of these (R.M. Pearson, 1993). These disagreements partly arise from competition between specialisms, and the tendency to work in narrower and narrower specialism rather than to view problems, diagnosis and treatment from a more holistic perspective. It is important to recognize that these problems have only been presented in large numbers within the last ten to fifteen years. In the absence of any sustained and reliable epidemiological studies, the current battles reflect the inability of conventional medicine to respond adequately to a changing pathology of occupationally-related injuries.
'If we can't find it in the body, it must be all in the mind'
As well as denying the existence of RSI, and the dispute over its physiological nature, there is also a broad body of medical opinion which asserts that the symptoms have a psychological cause. This argument asserts that the pain and other symptoms presented by sufferers result from unresolved psychological conflict or emotional disturbance (Bammer and Martin, 1988). This argument is most strongly proposed by Lucire, a female Australian psychiatrist who argues that RSI is a form of conversion disorder or mass hysteria in which patients exhibit neurotic reactions to keyboards and movements which have become symbols of danger to the vulnerable defined by Lucire as 'eggshell personalities, usually compulsive or dependent people who are powerless and dependent and who cannot otherwise express their righteous rage at their supervisors, employers and spouses, so resort to the use of their exquisitely symbolic pain as a mode of communication of their distress' (Lucire, 1986: p. 325). Needless to say those who support the view that the condition has a psychological basis are also aware that the majority of sufferers are women:
The condition commonly affects young to middle-aged and predominantly female employees engaged in low paying, monotonous low prestige occupations. The symptoms fail to respond to any form of treatment other than psychological counselling.... The treatment of RSI is unrewarding as it requires the patient's acceptance of the psychological basis of their condition.... It is surprising how often unsatisfactory social, family, marital and economic circumstances are expressed as job dissatisfaction.
(Ireland, 1988: p. 9)
Some commentators even suggest that sufferers fake physical symptoms which they have learned will earn them an appropriate diagnosis, or present symptoms consistent with hysteria:
[they] describe 1,000 patients, mostly female workers in offices and factories, and a very typical attitude of the affected upper limb, with half flexion of the elbow, wrist and fingers, without evidence of muscle atrophy.... Nowhere do they suggest that this posture is learned, whether consciously or not. Its pattern of incidence is like complaints of koro in South East Asian Chinese (sudden anxiety about recession of the penis into the surrounding skin), hysterical overbreathing in teenage girls at pop concerts, or several (other) conditions.
(Patkin, 1993: p. 11)
The last writer goes on to compare 'outbreaks' of ERS with outbreaks of computer-related 'facial dermatitis' in Sweden, angina in computer operators in North Carolina, and mass hysteria at a workplace in Singapore. It should give us pause for thought that the assumption here is that all these events were hysterical manifestations, rather than having a physiological explanation linked to the technological and organizational nature of the labour processes. This view of the nature of RSI cannot be understood without an appreciation of the trajectory of RSI in Australia, which is described below.
RSI: the Australian disease
The rapid growth of manifestations, diagnoses, compensation and dispute about RSI in the mid 1980s resulted in RSI being called the Australian disease, the Australian epidemic, or 'kangaroo paw'. This designation refers both to the emergence of the condition and public debate about it within Australia, and the suggestion, often made quite explicit, that RSI was a condition which was only manifest in Australia, because of the incentive for workers to produce symptoms which would enable them to get compensation.
A number of published studies contain succinct descriptions of the 'Australian disease' (Hall and Morrow, 1988; Hopkins, 1990; Reid et al., 1991; Bammer and Martin, 1988; Meekosha and Jakubowicz, 1991). One version is as follows:
In Australia between 1983 and 1987 there was an epidemic of upper limb regional pain which was concentrated among workers in occupations which involved either repetitive movement, or the adoption of constrained postures for lengthy periods of time (e.g. process workers and keyboard operators). Although the phenomenon of upper limb pain was observed among process operators in the late 1960s and early 1970s it only achieved epidemic status in 1983 when the first claims began to be made under workers' compensation. The rate of claims increased dramatically during 1984 and 1985, persisted through 1986, and then equally dramatically declined in 1987. The consensus of informed opinion is that the worst of the epidemic has passed.
(Hall and Morrow, 1988: p. 645)
Other accounts of the same phenomena are more cautious about making such an unproblematic link between the availability of workers' compensation and the rise and fall of RSI in Australia. Certainly the 1980s saw a rise in the number of cases recorded, in the number of people seeking compensation, and the number of computer keyboard operatives, particularly in the public service. The number of new notified cases has now diminished. However the assumption of a causal relationship between the availability of compensation and the incidence of RSI is rather suspect.
Part of the story lies in the fact that from the early 1980s the Australian government explicitly recorded the incidence of RSI, and accepted compensation claims on the basis of certification by the claimant's own doctor, who needed only to state that the claimant was suffering from RSI and required a specific period of rest (ibid.: p.367). In the United States and Britain at that time there was no available source of national information on the incidence of such conditions (Putz-Anderson, 1988b: pp.604- 605).
The absence of public recognition of RSI as an occupational and therefore compensatable disease in other countries meant there was less public awareness of the issues, and this reinforced the view in Australia that there was no comparable condition elsewhere, in spite of extensive, if not systematic, data relating to its prevalence in the United States, Scandinavia, and Japan (Hopkins, 1990: pp.366-367; English et al., 1989; Bammer and Martin, 1988; Polakoff, 1991)
The reported decline in notified RSI diagnosis in Australia was not the result of a reduction in the incidence of the symptoms of the condition. It was directly related to changes in the compensation procedure, rehabilitation programmes and medical and legal delegitimation of the condition (Meekosha and Jakubowicz, 1991). In many states the system was modified to reduce statutory employer liability and to introduce mandatory rehabilitation programmes. Instead of institutionalizing employer liability, the state has joined forces with those seeking to devalidate claimants' cases by arguing that the condition is psychological in origin. As the medical controversies rage on, workers who have participated in mandatory rehabilitation programmes report a lack of professional support and the exacerbation of their condition by intensive testing procedures. The rehabilitation therapy, officially designed to assist sufferers in regaining fitness to work, has been transformed into an official routine to deny people's perception of their own pain and mobility:
A major issue for interviewees is the pain involved during and after the key test.... Many expressed shock at receiving an assessment that they were fit for work when they had felt sure that the pain they had reported during the test would have indicated that they were not fully recovered.
(ACT RSI Support Group, 1991: pp. 4-5)
In spite of the apparently positive attitude towards health hazards in the 1980s, the acrimonious debate has altered public and professional perceptions of RSI. The standard explanation that RSI in Australia is the result of the increased pace and duration of keyboard utilization, in ergonomically unsound workplaces, has been undermined (Bammer and Martin, 1998). Alternative hypotheses are that people with RSI are malingerers who don't want to work, who suffer from a form of compensation neurosis (whereby symptoms disappear in the absence of financial gain), that it is a form of psychological hysteria or conversion neurosis (as discussed above), or that RSI is a manifestation of normal fatigue experienced by all sectors of the population with no underlying injury or pathology. These counter hypotheses have a distinct gender bias, as was apparent in the earlier citations referring to dependent personalities, women in repetitive unskilled jobs, and various forms of neurotic dispositions.
Reid et al. ( 1991) have described the experiences of women sufferers of RSI in the increasingly hostile climate of Australia's legal, medical and compensatory systems as a 'pilgrimage of pain' in which women's encounters with the system 'contributed to the chronicity, unemployment, bewilderment and despair reported by so many' (ibid.: p. 602). Their research indicates that the 'polarized environment characterised by doubt, derision and debate' (ibid.) in which sufferers sought advice and treatment, created a situation in which judgements were made about their situation which were directly linked to their gender, family circumstances, body shape and emotional distress. Professionals and experts revealed prejudices about semi-skilled women workers which reflected class and gender conflicts in the wider society.
This is underlined by the recent publication of a number of studies in the medical journals which report on research on 'overuse syndrome' amongst musicians (Fry. 1986, 1988 and 1993; Dennett and Fry, 1988; Lippmann, 1991). These studies have examined the similarities between musicians' 'overuse syndrome' and repetitive strain injury of keyboard and process workers (Bammer, 1993). Although mainly addressing medical analysis, the implications in terms of the prejudices of the experts dealing with RSI are not lost on all writers:
Much of the heat in the debate over whether occupational overuse exists as a clinical entity has centred on whether the examining physician believes the patient. The problems lie in the lack of objective clinical signs and repeatable investigative tests. Excluding clear cut tendinitis, synovitis and carpal tunnel syndrome, other entities, even as diagnostically straightforward as epicondylitis lack objectivity. When one moves proximally towards the shoulder and neck the problems are greatly increased.... The two schools of 'real illness' and 'malingerers' shape up to each other in the courtroom, provide a field day for the lawyers, but do little to help the patients.
How can we get closer to resolving these issues? After all, many of the 'sufferers' are poorly paid manual workers undertaking soul destroying repetitive tasks. They have much to gain from compensation and a respite from occupational boredom. They are also likely to slip inexorably into chronicity.
The search for truth in the patients' symptoms is thus frequently dogged by the knowledge that they would be advantaged by stopping work and indeed their intellectual powers may preclude a good history in the first place. The position of professional and student musicians is in marked contrast. Here are a group of intelligent, highly motivated individuals who have everything to lose if they develop a disabling pain, and yet their 'work' involves repetitive movements and abnormal postures.
. . . musicians develop symptom-sign complexes of overuse syndrome indistinguishable from those of less gifted and less motivated workers undertaking work practices which involve comparable hand-arm movements. Ballet dancers develop equally disabling pain and tenderness but in the lower limbs. Again here is another group for whom changing employment would be a disaster.
If we 'believe' the disease to be genuine in dedicated artists, should we not approach the lowly manual worker with more open mindedness? After all, the overuse is genuine and obvious in both groups. The belief in the effects is being driven by our preconceptions of patients and their motivations. Dr Fry has done us all a service by his work into the occupational hazards of the performing arts. It does not provide the incontrovertible proof we all seek, but should make those who espouse the malingering theory to sleep less easily in their beds.
Because the 'lowly manual workers' are in fact women keyboard operators, the assumption is that they do not need to work. This is the familiar gendered notion that women's wages are not central for her household, and that paid work is not central to the identity and self image of women in the same way as it is for men. As another medical 'expert' commented, most of the people who consulted him with RSI symptoms were characterized by 'short periods of involvement in the workforce, impulse resignations and unsatisfactory relationships with other workers . . . like the depressed subjects, the women who have conversion reactions frequently reported difficulty with their employers' (Black, 1987, cited in Meekosha and Jacubowicz, 1991).
It is true that women are the majority of RSI sufferers. In 1984, women accounted for 2,800 of the 3,022 cases reported amongst civil servants in New South Wales (Meekosha and Jakubowicz, 1986).
Whilst the debate about the genuineness of the symptoms continues, it is not totally clear that the 'epidemic' in Australia has subsided. The basis for recording the figures has been changed and researchers report that it is now very difficult to obtain data on RSI incidence. Moreover with more public consciousness of the problem, employers are carrying out pre-employment checks which are aimed at eliminating stereotypically RSI prone applicants, which also has the effect of intimidating other employees from making complaints or taking action. It may also be that the apparent decline in incidence relates to better keyboards and changes in the kinds of work being carried out (Meekosha and Jakubowicz, 1991).