the social recognition of repetition strain injuries: an australian/american comparison

SW. Sci. .Wrd. Vol. 30. No. 3. pp. 365-372. 1990 0277-9536,90 f3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright c 1990 Pergamon Press plc

THE SOCIAL RECOGNITION OF REPETITION STRAIN INJURIES: AN AUSTRALIAN/AMERICAN

COMPARISON

ANDREW HOPKINS

Department of Sociology, The Faculties, Australian National University, GPO Box 4, Canberra, ACT 2601, Australia

Abstract-In the mid 1980s the problem of occupational overuse injuries, particularly among keyboard operators, gained widespread recognition in Australia. The country appeared to be experiencing an epidemic, the like of which was unknown elsewhere in the world. Three explanations are canvassed in the paper: first, the psychiatric theory that it was a case of ‘epidemic hysteria’; second the hypothesis that there really were more such injuries in Australia than elsewhere; and third, the hypothesis that the institutions of Australian society facilitated recognition of the problem, while those of other countries repress awareness of it. The paper focusses on this last hypothesis and seeks to demonstrate it by means of a comparison between Australia and the United States. It shows how, in particular, the system of workers’ compensation in the Australian public service facilitated recognition of the problem, while the compensation system in the United States makes it very difficult for sufferers to have their disability acknowledged. Since workers’ compensation is virtually the only source of injury statistics, this has led to the visibility of the problem in Australia and its invisibility in the United States.

Key words-repetition strain injury, workers’ compensation, cumulative trauma disorders

INTRODUCTION

In the mid 1980s Australia saw a rapid rise in reports of upper limb pain (in fingers, wrists, arms, shoulders and neck), largely among workers whose jobs involved repetitive hand movements. Although assembly line workers are most at risk in this respect, the greatest publicity was given to keyboard workers, among whom the problem seemed to be occurring in epidemic proportions. Repetition strain injury (RSI), as it was called, became a focus of media attention and professional concern, and the acronym, RSI became a household expression. What little evidence there is suggests that the number of new cases among keyboard workers peaked about 1985 and declined thereafter [ 1, 21.

It has been widely claimed that RSI is a purely Australian phenomenon. The Australian Medical Journal is full of suggestions that it is an “Australian disease” [3] and skeptics have labelled it “kangaroo paw” [4,5]. More cautiously, it has been said: “currently there is no similar epidemic of upper limb pain anywhere else in the world” [6].

Sometimes the claim is even more area-specific. Canberra has been labelled the RSI capital of Aus- tralia [7], no doubt because of the publicity given to cases of RSI in the federal public service.

The inference often drawn by writers who make these claims is that RSI is essentially a “non-existent disease” [8]. Perhaps the most widely known version of the non-existence thesis is that RSI is a form of epidemic hysteria [9, IO], in which psychological conflict is subconsciously ‘converted’ into physical symptoms. The choice of symptoms is suggested to the sufferer by the social environment, essentially, by what is fashionable. Hence the apparently epidemic nature of the problem.

However, the hysteria theory has been shown to be inconsistent with much of what is known about the RSI epidemic [ 11, 121. For example, it has been much longer lasting than other historically documented instances of epidemic hysteria, which are normally sudden in onset, building to a climax within a few weeks and abating just as quickly [12].

The principal exponent of the hysteria theory, Lucire, herself assumes a different trajectory for the epidemic: it will last, she says, as long as compensation is available.

As long as compensation is paid for functional (i.e. non- organic, non-physical) symptoms as if they were the result of a hypothetical “injury”, symptoms are rewarded and reinforced, and the epidemic will continue to spread. . . . Control of this epidemic will require a complete with- drawal of the injury theory and its mythology and terminology [9, p. 261.

Lucire is factually wrong on this point: the epidemic is now waning despite the continued payment of compensation to the great majority of victims. (An exhaustive critique of Lucire’s arguments has recently been published [ 131 and need not be repeated here.)

A closely related variant of the non-existence thesis is that RSI is essentially a form of malingering, with workers consciously faking symptoms in order to receive workers’ compensation. Although such suggestions are often made in conversation, they have seldom been advanced in print in any credible way [14].

There are two other possible explanations for the fact that RSI has attracted greater public attention in Australia than in other countries. The first is that the incidence of the problem really is greater in Australia than elsewhere. There has been some research and a good deal of speculation based on this assumption. It

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366 ANDREW HOPKINS

has been convincingly shown, for example, that the rise of the problem in Australia coincided with the introduction of new word-processing equipment and the increased work pressures that accompanied this change [15, 161. In this connection it is noteworthy that the decline of the epidemic has corresponded with the implementation in the workplace of strate- gies designed to prevent the occurrence of RSI [17]. There has also been speculation that the epidemic in Australia was due to the dumping of inferior key- boards on Australian markets by multinational cor- porations [!8] and to the presence of fluoride in Australia’s water supplies [9], but there is little evidence to support these claims.

The other possible line of explanation is that, regardless of the actual incidence of the problem, there is something about the societal response in Australia which has facilitated its recognition, while conversely, the social and institutional response in other countries has had the effect of repressing public awareness. These two exp!anations-differentia! incidence and differential societd! response-may, of course, be simultaneously true.

This paper will focus on the latter: the way in which the institutional response to the problem in Australia has contributed to its widespread recognition. The method will be comparative, contrasting Australia with the United States, a country where RSI, particularly among keyboard operators, has not become a matter of serious public concern. The paper is based on documentary materials available in Canberra and Washington, together with a series of discussions with officials in both countries.

DOES RSI EXIST IN THE UNITED STATES?

The research reported here was not designed to adjudicate among the theories outlined above, but merely to demonstrate the role of institutional factors in generating or suppressing public awareness of the problem of RSI. Nonetheless, data gathered in Wash- ington do enable something to be said about the differential incidence hypothesis.

There are no figures available which would enable a straightforward comparison of the incidence of RSI in the two countries. There are figures, however, which show that the problem is widespread in the United States. In its annual survey of occupational injury and illness in the private sector, the United States Occupational Safety and Health Administra- tion (OSHA) found over 78,000 new cases of what it calls “disorders associated with repeated trauma”, which it further specifies as including “noise-induced hearing loss and conditions due to repeated motion, pressure, or vibration, such as carpal tunnel syndrome” [20]. OSHA estimates that hearing loss cases form only a very small proportion of this category, the remainder being what, in Australia, would be called repetition strain injuries.

These figures are certain to be an underestimate. They are based on returns provided by employers which are then used by OSHA in targeting high risk industries or enterprises for inspection. There is thus a built-in incentive for underreporting, which has been so flagrant that OSHA has recently taken legal action against selected offenders [21].

Other evidence comes from the National Institute of Occupational Safety and Health (NIOSH) which estimates that six in every 100 workers suffer from ‘cumulative trauma disorders’, the most commonly used American term for RSI [22].

Most of the injuries referred to above occur in the manufacturing sector. But there is considerable, if less systematic, evidence of RSI specifically among keyboard workers in the United States. For example:

l in 1985, 700 post office keyboard workers were reported to have applied for compensation for RSI WI; l an outbreak of RSI among editorial staff of the Los Angeles Times lead the paper to re-equip its offices with ergonomically sound work-stations [2X P. 511; l 68 keyboard operators working for the telephone company Mountain Be!! in Denver were diagnosed in 1987 as having RSI (tenosynovitis and carpal tunnel syndrome). After considerable union pressure the company instituted a number of ergo- nomic changes [23, pp. 110-l 111.

There is little indication, however, of RSI amongst secretarial workers, a group which has been prone to RSI in Australia [2]. Whether this amounts to evidence of absence or merely an absence of evidence is hard to say. Employers of secretaries I spoke to in Washington had never heard of the problem among their staff and advanced a number of reasons for its supposed absence. First, their secretarial workers are seldom straight typists; in the federal service they are designated clerk/typists and their duties are quite varied. Second, at least in Washington, secretarial workers are in short supply-scarce as gold, I was told-and hence can shop around for better conditions if employers put excessive pressure on them. Third, and relatedly, many of them have tertiary qualifications and expect varied and interesting work. Fourth, the women’s movement has made secretaries more assertive than formerly. Fifth, most professionals now do their own keyboard work on persona! computers, thus reducing the need for typing assistance.

Many points of contrast with Australian secretaries are apparent in this list, but such speculation is really premature in the absence of any real data on the incidence of RSI among secretarial workers in the US. One good reason for skepticism about the supposed absence of RSI among secretaries in the United States is a small pilot project for an international study which found evidence of RSI among certain groups of university secretaries in the United States and several other countries [24].

Though far from systematic, the preceding discus- sion is enough to indicate that RSI, even among keyboard operators, is not unknown in the United States. Whether the incidence is comparable with that in Australia is impossible to say. But it would clearly be hard to argue that the absence of any widespread public awareness of the problem in the United States is simply attributable to the absence or insignificance of the problem. It is the thesis of this paper that the differential response of the institutions of the two

The social recognition of RSI 367

societies has played an important part in generating an awareness of the problem in one case and suppressing it in the other.

THE IMPORTANCE OF NAlMING

The first critical difference has been in the naming of the phenomenon. In Australia, tendinitis, tenosynovitis, bursitis, etc. have long been known in compensation statistics. In the late 197Os, however, newly established workers health centres began to use the term ‘tenosynovitis’, or ‘teno’ for short, to describe all the repetition injuries they were finding among their predominantly blue collar clientele [25].

Subsequently, as reports of problems among keyboard workers began to appear, the term ‘repetition injury’ became more widespread-for example, the Australian Public Service Association published a pamphlet with this title in 1980-and in 1982 the National Health and Medical Research Council put out guidelines on how to deal with ‘repetition strain injuries’ [26]. The new term was legitimated by its use in article titles in the Medical Journal of Australia in 1983 and early 1984 [27,28] and the acronym RSI quickly passed into widespread use, replacing all other terms. Newspaper headlines invariably spoke of ‘RSI’ and such was the acceptance of the term that many doctors simply diagnosed RSI in cases of work-related injury, rather than seeking a more precise medical diagnosis. Despite complaints in some quarters that RSI was a term unknown to medicine, it became a very concrete malady in the public mind. In short, the existence of a simple and universally used term in Australia facilitated the social recognition of the problem.

In the United States the converse has been the case. The specialist literature in OHS has tended to employ the term ‘cumulative trauma disorder’ [29], the meaning of which is far less clear to the general public than ‘repetition strain injury’. For this reason, the few newspaper articles which have appeared in the United States have tended to confuse the issue by using the term ‘repetitive motion injuries’ in their headlines and then writing about ‘cumulative trauma disorders’ in the text [22,30]. The influential Bureau of National Affairs has written about the problem under its Australian name of ‘repetition strain injury’ [23, p. 5481, while the National Council on Compen- sation Insurance refers to ‘musculo-skeletal problems’ [23, p. 591. None of these terms has generated a widely accepted acronym.

The matter is even more confused than this. In individual cases, the specific medical diagnosis is often ‘carpal tunnel syndrome’ (nerve damage in the area of the wrist known as the carpal tunnel). As a result, a number of unions have issued pamphlets describing carpal tunnel syndrome and sometimes the related problems of tendinitis and tenosynovitis. Clearly, none of these more precise medical terms has the easy appeal of ‘RSI’. But more importantly, the absence of any consistently applied terminology in the United States hinders the widespread public recognition of the problem of injuries caused by repetitive motion.

WORKERS’ COMPENSATION

The naming issue is really only a preliminary matter. The most important differences in the response of the two societies are to be found in the systems of workers’ compensation and the statistics they have generated. Before developing this point we need to be clear on the various interests involved in workers’ compensation.

Legislation exists at both state and federal level in both countries requiring employers to compensate workers who suffer illness or injury as a result of work. Compensation usually takes the form of some fraction of the employee’s salary, if off work, plus medical expenses. The primary interests involved are thus those of the employee, who asserts employer liability for the injury or illness, and the employer. who has an interest in denying liability.

The employer is often backed by an insurance company, but government and many large employers do not insure themselves in this way and are termed ‘self-insurers’. The fact of insurance does not alter the fundamental conflict of interest between employer and employee, because the insurance premium paid is normally a function of the number of successful claims made against the employer. Employers and their insurers, on the whole, have a shared interest in minimizing their liability for compensation.

A third significant party is the legislatively established body whose function it is to adjudicate compensation claims. This may be simply an administrative agency, an office of workers’ compensation. a more formal board, or even a fully fledged court.

WORKERS’ COMPENSATION IN THE AUSTRALIAN PUBLIC SERVICE

Let us consider how this system operates with

respect to RSI claims in the Australian federal public service, which seemed in the mid 1980s to be the employer hardest hit by the problem of RSI. Public service agencies (departments or authorities) are self- insurers and the adjudicating body is the Office of the Commissioner for Employee Compensation (OCEC). At the time in question (although not since 1988) the Commissioner delegated most of this authority to ‘delegates’ in each agency, who were often simply the staff or personnel officers of the agencies.

There is, obviously, a possible conflict of interest involved in allowing an agency representative to adjudicate claims against the agency. So, to ensure that the procedure did not in fact bias the decision against the employee claiming compensation, the delegate was entitled to allow claims, but not to deny them. Any claim which the delegate felt should be disallowed had to be referred to the Office of the Commissioner [3 11. There was thus an administrative bias in favour of the employee.

In practice, the policy of many agencies was to accept compensation claims on the basis of certificates provided by the claimant’s own doctor, which often simply stated that the claimant was suffering from RSI and needed a specified period off work. Indeed, delegates were instructed to act in this way in the following directive, issued by OCEC in March 1985.

368 ANDREW HOPKINS

Claims for compensation because of RSI should generally be granted where a claim is supported by medical evidence from the treating doctor that the employee is unfit to work because of RSI and the delegate considers that the condition is work-caused or work-related. In most cases. where the employee has been engaged in work of a manual, repetitive nature and the treating doctor certifies the condition to be consistent with the stared cause, a delegate can accept that the condition is work caused or work related (emphasis added) ~321.

Dissatisfied agencies or claimants may appeal to an Administrative Appeals Tribunal, but only a tiny fraction of cases in fact lead to such disputes [33]. The system, then, at the height of the epidemic, offered little resistance to the injured employee claiming compensation.

Furthermore, the compensation paid amounted to 100% of the employee’s normal salary. There was, consequently, no significant financial penalty involved in opting for compensation.

At this point a further aspect of the institutional response becomes relevant. The federal Labor government, sensitive to the interests of its employees, established a task force to investigate the problem of RSI among federal workers and, shortly afterwards, began a quarterly census of all staff “involved in any RSI-related action”. This phrase was largely interpreted by those responsible for providing the information as meaning “being in receipt of compensation for RSI”. Although medical certificates did not always specify the complaint as RSI, agencies seemed to be in no doubt about which were RSI cases and had little difficulty in providing the information required. The figures were published four times a year, providing much publicized evidence of the rise, eventual stabilization and then slow decline of RSI in the federal public service.

It is important to note that the workers’ compensation system is the only source of figures in Australia on the extent of occupational injury and disease. Thus, the sensitivity of the compensation system to claimants’ interests was crucial in alerting the authorities to the extent of the problem.

It is important to note, too, that it does not follow from this that the epidemic of RSI in the Australian Public Service was merely an epidemic of compensation claims, unrelated to any real increase in the underlying incidence of the problem, as has been argued by some [9]. While it is true that the compensation system described above is open to abuse, it is also true that it facilitated genuine claimants whose RSI might not otherwise have been recognized.

WORKERS’ COMPENSATION FOR UNITED STATES GOVERNMENT EMPLOYEES

In the United States, compensation systems vary enormously from one jurisdiction to another. For the sake of manageability and to maximize comparability with the system just discussed, I shall focus here on the system applying to federal employees.

Many of the compensation systems operating in particular states are adversarial in nature, with claimants frequently facing employer representatives in court-type hearings. The federal system is designed to avoid this. Claims are settled by claims examiners

in an office of workers’ compensation. An appeal structure exists for employees, but, unlike almost all state systems, no appeals by employers are possible.

Although this feature might appear to favour claimants, the whole decision-making process of OWCP (Office of Workers’ Compensation Programs) serves to discourage claimants. Unlike the system for Australian federal employees, where claim forms are forwarded by the employing agency, the employee in the United States must personally send the claim to one of the 14 branch offices of OWCP around the country. Moreover, the ‘burden of proof’ is explicitly on the claimant to establish that the work situation caused or contributed to the injury and that the injury is incapacitating. Should the initial documentation be insufficient, the claims examiner ‘develops the evidence’ by requesting further documentation, medical tests, etc. and the whole process may take many months to complete. Furthermore, the employing agency is invited to ‘contravert’ (i.e. dispute) the claim and such contraversion is taken into account by the claims examiner, although it is not necessarily a decisive factor.

While this procedure is not particularly onerous in the case of claims for ordinary injuries, such as cuts or breaks, employees claiming compensation for repetition strain injuries confront quite considerable obstacles. Unlike Australian compensation systems, in America a crucial distinction is made between traumatic injuries, that is, injuries which occur at a particular time or in the course of a single working day, and occupational illness or disease, which develops over the course of more than one day, for example, hearing loss [34]. By this definition repetition motion injuries are diseases. This categorization has far reaching consequences, for OWCP treats disease or illness quite differently from injury.

For a start, the claim forms are different, illness claims requiring considerably more information than traumatic injury claims. The employee must provide pages of detailed description of the nature of the complaint, the circumstances of its development. treatment history, other activities which might have contributed to the condition and so on. The medical report supplied by the treating physician (chosen by the patient) must include a detailed description of the doctor’s findings, results of X-rays and laboratory tests and a reasoned account of why the doctor thinks the condition was caused or aggravated by employ- ment. The claim form explicitly notes that medical reports which do not explain the basis of the doctor’s conclusion that the condition is work-related are given very little weight in claims adjudication.

In the case of claims for ‘occupational stress or strain’ -and this would cover many RSI cases-the OWCP-procedures manual instructs claims examiners as follows:

The claimants are prone to generalize in stating the basis of their claim, whereas there is a great need for specific allegations. In all cases, the claims examiner must be particularly careful to require detailed allegations of the claimant which are sufficiently specific.

The disabilities are not peculiarly of industrial origin. They may, and in many cases do (emphasis added), have their origin in the employee’s structural makeup or personal life activities. In all cases, the claims examiner must be


particularly careful to develop the facts about the prior medical and industrial history and possible causes in the employee’s personal life and activities [35].

The manual goes on to advise that in such cases it may be necessary for an OWCP representative to make an on-site investigation.

The contrast between the extreme caution of above statement and the liberal position of the Australian Commissioner for Employee Compensation described earlier could hardly be more striking. It stems, no doubt, from the fundamentally different position of organized labour in the two countries, of which the most obvious manifestation is the existence of a Labor Party in Australia but not in America.

In cases of carpal tunnel syndrome, the most common medically specific RSI diagnosis, OWCP requires the treating doctor to provide the following test results or findings [36]:

Phalen’s sign test, Tinel’s sign test, a finding of decreased sensation in specified parts of specified fingers, nerve conduction velocity test results, electromyographic test results.

Clearly, there are formidable evidentiary require- ments which any RSI victim must satisfy to obtain compensation. Indeed, a claims examiner I inter- viewed in Washington spoke of the ‘burden of evidence’ as being far more of a problem for claimants than the ‘burden of proof’, which formally they carry.

Not surprisingly, such claims take many months to finalize. OWCP’s guidelines call for it to decide 70% of illness claims within 6 months and 90% within 10 months (interview with OWCP official). While the existence of such guidelines is, in itself, laudable, the time limits specified give some indication of the long delays which illness victims can expect before receiving any form of compensation.

In the case of RSI claims, the delay can be in excess of 2 years. In the federal Social Security Administra- tion headquarters near Baltimore, a union representative I spoke with knew personally of 12 keyboard workers suffering from RSI who had made claims in the previous 2 years. Some had even undergone carpal tunnel surgery, but none had yet been granted compensation. Their claims had not be denied; they simply remained undecided while OWCP sought the required documentation. In the meantime these employees stayed at work, unable to carry out their full range of duties. Some had been informally re- deployed while others were being threatened with disciplinary action because of their failure to perform their normal duties.

Once a claim is authorized it is back-dated to the time when the person was disabled, but compensation for wages lost is at the rate of two-thirds of normal salary, or three-quarters if the claimant has depen- dents. Thus, apart from the administrative hurdle, there is a financial disincentive to taking time off on compensation and many employees in this situation will choose to take whatever sick leave they have rather than apply for workers’ compensation.

Moreover, workers in the United States are often covered by private, employer-sponsored medical insurance, which readily reimburses them for medical expenses (though not lost wages), further reducing the incentive to apply for workers’ compensation [29, p. 1351.

The contrast with the Australian system goes further. Whereas in the Australian case the numbers of federal RSI compensation claimants were identified in a census and the results published, there are no published figures on the numbers of federal employees in the United States receiving compensation for RSI. Furthermore, the methods by which the data are coded make it difficult, if not impossible, to extract such information from the records. At present, federal compensation data are available on the part of the body affected-there were, for example, about 10,300 injuries to arms or wrists in 1987 (unpublished data, obtained from OWCP)--but the type of injury is not specified. There are separate data available on the nature of the injury (for example there were 1803 multiple strains), but nowhere in the data does the diagnosis carpal tunnel syndrome or tenosynovitis appear, nor the more general terms cumulative trauma disorder or repetitive motion injury. Thus, even if large numbers of employees were obtaining compensation for RSI, which seems un- likely, there would be no reliable or systematic way of knowing. (A recent change in recording procedures may allow RSI cases to be identified in the future.)

THE CASE OF UNITED STATES POSTAL WORKERS

The failure of the compensation statistics in this respect is evident in the case of the serious RSI problem which is known to exist among United States postal workers. The case also demonstrates the reluctance sometimes shown, even by federal agencies, to accept liability for RSI. In the early 1960s the United States Post Office installed letter sorting machines (LSMs) in most of its mail exchanges. These required the operator to sit at a keyboard, keying in the post codes of letters passing before him or her at the rate of about one a second. In congressional testimony given in 1984, a representative of the American Postal Workers Union recounted how RSI problems began to develop soon after the machines came into operation. Beginning in the mid 70s a series of studies had demonstrated the existence of a serious problem among LSM operators. According to the union testimony, 50% of operators had reported pain in arms, neck, hand or shoulder, 30% had been diagnosed as suffering from carpal tunnel syndrome or tendinitis and 20% had had carpal tunnel surgery to relieve the pain [37].

The Post Office, however, has refused to acknowledge that its machines are the cause of the problem, on the grounds that not every centre where the machines are in operation has reported RSI problems. It prefers to attribute the injuries to the personal characteristics of operators. For this reason it has contraverted (disputed) every compensation claim by LSM operators. OWCP has nevertheless accepted many of these claims and the view expressed to me by an OWCP official was that the Post Office worked harder than any other agency at contraverting claims

370 ANDREW HOPKINS

and taking punitive action against employees report- ing injury.

Postal officials complained to me that a booklet put out by the union on carpal tunnel syndrome ‘re- hearsed’ employees on the symptoms of the problem and, in effect, told them how to ‘fake it’. Indeed, a sign I saw in a postal service compensation office advised workers in big red letters not to ‘fake it’. It is clear that the agency would appeal every RSI compensation award against it in court, if that were possible under United States law.

The point is that none of this is apparent in OWCP data. Despite a welter of documentation on the Post Office problem and the acceptance of numerous compensation claims for carpal tunnel syndrome, the epidemic of RSI among the nation’s 50,000 LSM operators is invisible in official statistics. There is, it should be noted, no source of statistics on occupational injury and disease among federal employees, other than compensation figures. Thus, the fact that OWCP is unable to provide data on RSI cases among federal employees can be seen as contributing significantly to invisibility of the problem in the United States, in marked contrast with the situation in Australia.

STATE COMPENSATION SYSTEMS IN THE UNITED STATES

So far the focus has been on the federal compensation system. A few words about the state systems will suffice to indicate that, on the whole, they are even less receptive to RSI claims than their federal counterpart.

For a start, in some states, musculoskeletal ailments such as RSI have been excluded by legislation from workers’ compensation coverage on the grounds that they are ‘ordinary diseases of life’ suffered by much of the population [23, p. 601.

Second, in some states patients are required to go to doctors selected by the compensation authorities. Should they choose to go to their personal doctor, that doctor’s report will not be recognized and the bill will not be paid. The selected doctors, of course, will be cautious about concluding that the problem is work-related.

Third, where an employer contests the claim, as would often happen with RSI cases, the matter is decided in a formal hearing before a board or court and claimants feel compelled to hire legal counsel. Even if the decision is in favour of the claimant the employer is free to appeal and is strongly motivated to do so, to avoid what could be a costly precedent. The cases of 34 keyboard operators with RSI who experienced such difficulties are documented in a union publication ‘VDT Syndrome: The Physical and Mental Trauma of Computer Work’ [38].

It is clear from the preceding comments, and particularly from the adversarial nature of state compensation systems, that the states are even less likely than the federal administration to generate meaningful figures on the extent of RSI among keyboard operators, or to encourage public awareness of the problem.

GOVERNMENT CONCERN

One final comparative observation needs to be made. The Australian Labor government, which came to office in 1983, was concerned about occupational health and safety, setting up a National OHS Commission, a National Institute of OHS and, more specifically, a task force on RSI which produced a major report on the problem [32]. The OHS Commis- sion dealt with RSI as one of its top priorities and it, too, issued a report and guidelines on how to deal with RSI in the workplace [25]. By contrast, during the same period the Reagan administration exhibited a disdain for OHS matters and significantly reduced the budget and the effectiveness of the OSH Admin- istration [39,40].

The United States Occupational Safety and Health Administration, itself, has seemed oblivious to the problem of RSI among keyboard operators. In 1986 it published a pamphlet entitled ‘working safely with video display terminals’, in which it addressed the dangers of such work. After discussing radiation, noise and electrical hazards, it contained a brief section entitled ‘physical discomforts’. The section is worth quoting at length.

Video display operators do sometimes report eye fatigue and irritation, blurred vision, headaches, dizziness, and pain or stiffness in the neck, shoulders, back. arms, wrists and hands.. . . These problems.. involve ergonomics-the physical and environmental setting where the VDT users work. The relation of the operator to the keyboard and the screen, the operator’s posture, the lighting and the back- ground noise should be carefully tailored to prevent discom- fort. Moreover, humidity, temperature and ventilation should also be controlled. Actually, any prolonged mental or physical task can likely result in fatigue. Therefore, the type of task a VDT operator performs greatly influences the development of fatigue [41].

This statement is remarkable for its vagueness and for its failure to acknowledge that many of the complaints mentioned are in fact symptoms of an occupational injury or disease and might even be medically diagnosable as tenosynovitis or carpal tunnel syndrome. For an employee reading the pamphlet, its failure to provide a name for the symptoms which he or she may be experiencing clearly reduces the likelihood that the problem will be recognized for what it is and reported. In short, while the Australian government and its agencies played a role in publicizing the problem of RSI, there was no comparable activity on the part of the United States administration.

PUBLICITY FOR BLUE COLLAR RSI

Ironically, the problem of RSI among blue collar workers may be in the process of becoming better known in the United States than in Australia. Major articles on the subject have recently appeared on the front pages of various American newspapers [22,30,42,43]. Again, this is probably not because the incidence of RSI among blue collar workers is greater in the United States than in Australia, but rather because of the attention now being paid to the problem in the United States by one federal agency, OSHA. For essentially political reasons (complaints


by constituents to Congress members), the meat cutting and packing industry has recently come under investigation. OSHA found that 40% of the workers on the meat cutting line in one plant were suffering cumulative trauma disorders which the employer knew were the result of poor working conditions. In 71 cases, employees had undergone carpal tunnel surgery but had been forced back to work the following day by the employer. Confronted with this evidence, OSHA proposed to fine the company $4.33 million, the largest fine ever proposed against a single company [44]. (The fines are ‘proposed’ because they are always reduced in subsequent negotiations.)

Some months earlier, OSHA had proposed a penalty of $3.1 million against another meat packer for similar offences. This was subsequently reduced to $950,000, in return for an agreement by the company to set up a major research programme and to redesign much of its equipment and practices.

OSHA has also issued a pamphlet entitled ‘Safety and Health Guidelines for the Meatpacking Indus- try’, in which, unlike the pamphlet on VDTs, it uses the names ‘carpal tunnel syndrome’ and ‘cumulative trauma disorder’ and describes them as “widespread” and “very serious diseases that often affect workers whose jobs require repetitive hand movement and exertion”. It also notes that the effects can be permanent.

For whatever reason, then, OSHA has recently mounted a campaign to deal with RSI in the meatpacking industry and the result has been an increase in media attention to RSI and hence public awareness of the probiem.

By contrast, Australian health and safety inspec- torates have neither the expertise nor the financial resources to investigate RSI on the assembly line and have paid no attention to the problem. There has, in fact, been no significant institutional response to blue collar RSI in Australia and hence nothing like the public attention which has been focussed on the white collar area. These comparisons demonstrate yet again the critical nature of the institutional response in generating public awareness and concern.

CONCLUSION

This paper has canvassed three possible explanations for the visibility of RSI among keyboard workers in Australia in the mid 1980s: the hysteria theory, the differential incidence hypothesis and the differential societal response hypothesis. The first of these was shown to be inadequate in various respects, giving rise to the question: why did it achieve such prominence? It is ironic that, although RSI is not a peculiarly Australian phenomenon, its explanation as hysteria is. To be more specific, in RSI cases which have come to court in Australia, employers have tended to argue that the problem is imaginary, a result of hysterical conversion, while in the United States, the tendency is not to deny the reality of the injury, but to deny that it is work-related.

The reason for the difference is probably as follows. Court cases in the United States are usually about seeking to establish initial eligibility for compensation, at a time when the medical evidence of pathology is reasonably clear. In Australia, on the

other hand, court cases are initiated by employers/ insurers to shed liability for a worker who has been off work and on compensation for many months, if not years. In these circumstances, detectable signs of RSI (swelling, etc.) have long since disappeared and doctors become frustrated by and unable to account for continuing complaints of pain. In the face of this medically inexplicable pain there is a tendency to resort to concepts such as ‘conversion disorder’ and ‘compensation neurosis’ as explanations. This view fails to acknowledge that RSI may result in perrna- nent disability. Interestingly, insurance companies in the United States readily admit that tenosynovitis and carpal tunnel syndrome may involve permanent disability [23, p. 59; 451.

A second possibility was that the real incidence of RSI was much higher in the mid 80s in Australia than in other countries. The paper concentrated, however, on demonstrating a third hypothesis, namely, that the visibility of the problem in Australia was in part due to the nature of the societal response.

It is well known to sociologists that statistics often tell us more about collection procedures than they do about the phenomenon they are supposed to reflect [46]. Thus, for example, an increase in arrests for a particular offence may be an outcome of an administrative decision to focus police resources on the behaviour in question, rather than an indication of any real increase in the incidence of the behaviour.

Another example, closer to the matter at hand, is the acknowledgement by compensation officials in Washington that the increase in claims for hearing loss that has occurred in the United States Airforce in recent years is not an indication of any increase in the incidence of the problem, but stems from a greater social recognition that hearing loss among airport workers is work-related and compensible. Clearly, similar social processes have been at work in Aus- tralia in relation to keyboard RSI.

None of this is intended to deny that there may have been a real increase in the underlying incidence of the problem in Australia in recent years. It is simply that such an increase will go unnoticed unless there is a system in place to respond to it. As Willis observes, citing Figlio [47].

(recognition of an epidemic depends on) the appearance of observers of the disease or injury who set in operation various medical, legal and administrative apparatuses to ‘cope’ with the disease or injury [7, p. 2121.

Moreover, given a favourable societal response, those who might otherwise suffer in silence, or even ignorance, are encouraged to come forward and be counted. In Australia, a generous compensation system, a regular RSI census, and the existence of the concept of RSI in the popular consciousness facilitated recognition of the problem among keyboard operators. In the United States, the absence of all these factors has tended to repress any such recognition.

A final comment is necessary on the politics of this argument, because of the ease of misunderstanding. I am not arguing that the compensation system cnused the RSI epidemic in Australia. I am arguing that it facilitated its recognition and, furthermore, that the American system retards recognition of the

372 ANDREW HOPKINS

problem. The last part of this argument must not be 24.

overlooked. Thus, if any policy conclusions are to be drawn, it is not clear from the evidence presented here that the Australian compensation system should be made more restrictive; it is clear, however, that the American system is failing and should be liberalized. 25.

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the social recognition of repetition strain injuries: an australian/american comparison

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