Secrecy and safety: health care workers in abortion clinics.

Astor, Sarah Todd

Whether [the anthrax threat] is a hoax or not, it's a criminal act and that act will be prosecuted to the fullest extent of the law.... It hit innocent people and I want to make sure that we do everything we can to protect those public servants. (1)

The people buying gas masks are trying to impose a shred of control over a potential threat that is silent, invisible. A monster that could arrive in the morning mail, on an autumn breeze--in your next breath. At least that's the fear. (2)

RECENTLY, I HAVE FOUND myself reading half-a-dozen breathless and fearful articles like the two above, describing the risk that anthrax poses for government and media employees. This threat has, at least momentarily, become a credible issue for workers. (3) As someone who has worked in an abortion clinic, watching my mail for "powdery substances" is not an unusual practice. (4) It has been a year since I was an abortion counsellor at a clinic in a large Canadian hospital. I remember the anthrax information session and the blue binder filled with protocols to be followed if clinic staff were exposed to this "dangerous powder." I remember opening unfamiliar packages with caution. What strikes me about recent news reports is how anthrax is perceived as a "new" danger for Americans and, to a lesser extent Canadians. This "new" threat, while no less deliberate and focussed than the anthrax risks to which abortion service providers are accustomed, is perceived as a broad social concern, whereas our earlier fears are not considered to be a general threat. Instead, the safety concerns of abortion workers are contained within abortion debates.

The media headlines rest in my thoughts as I write a paper about social workers and abortion services. I am reminded of the cultural ambivalence, if not silence, that surrounds abortion work and which, I argue, makes it difficult to position issues facing abortion workers in relation to more general workplace safety concerns. While we are able to recognize the potential threat that anthrax poses to workers now that it has entered "respectable" workplaces, the safety issues faced by abortion workers seem to be construed as "part of the job" when occurring in abortion clinics. I suggest that the safety concerns of abortion workers are linked to the vulnerability of all workers who may have jobs (or whose work comes into contact with jobs) that attract violence or threats of violence. In order to understand these links, we need to move beyond the sensationalized debates that often dominate any reflection on abortion services and attempt to understand the daily workplace risks faced by workers in these clinics. Although such a task is beyond the scope of this brief paper, I would like to use this opportunity to establish a conceptual framework for such a rethinking.

Three assertions ground my discussion. First, since 1988, abortions have been recognized as a legal health care service. As such, this exploration of the conditions under which abortion workers practice will focus on our experience as "everyday" practitioners of health care. In fact, abortion workers' daily tasks (and thus working experience) differ little from the employment experiences of any health care provider. Our days are full of providing accessible, safe, supportive, and responsible health care to people who have a right to these services. We are housekeeping staff, social workers, physicians, nurses, receptionists, and technicians. In these roles we provide, for the most part, ordinary health care services and go home to ordinary lives.

Second, workers in abortion clinics are often not pro-choice activists or "radicals." Although most workers in these settings are committed to women's access to legal and safe abortions, the cultural and religious ambivalence that surrounds abortion is also reflected in our daily struggles with the nature of our jobs. (5) In addition, when clinics operate within a hospital setting, some of the health care professionals engaged in this work have little choice as to whether or not their technical skills are implicated in the provision of abortion services. (6) As a result, many health care professionals approach their work in abortion clinics, not as a political practice, but as part of an imagined politically-neutral health care system. (7)

Finally, the daily practices of abortion workers take place within a hostile, often dangerous environment. Anthrax threats--sending powdered substances to clinics with notes inferring that the contents are anthrax--appeared as a method of harassing abortion clinic staff in the late 1990s. This was, however, just the most recent manifestation of what have been several decades of violence. (8) For some time, many of us working in Canadian abortion clinics could rationalize that, however tragic, these types of dangers only existed for clinics in the United States. Then, on 24 January 1992, Dr. Morgentaler's clinic in Toronto was bombed; on 8 November 1994, Dr. Romalis was shot and wounded in his Vancouver home; and on 11 November 1995, Dr. Short, a Hamilton doctor, was also shot and wounded while in his home. (9) In 1996, there was a butyric acid attack on the Morgentaler Clinic in Alberta, and in 1997, Dr. Fainman was shot and injured at his home in Winnipeg. Though most anti-abortion violence has been aimed at physicians, clinic receptionists, nurses, and security staff have all been terrorized, wounded, or killed because of their work in abortion clinics. (10)

This type of sustained yet unpredictable violence is, as Dr. Morgentaler has suggested, "a terror tactic to spread panic among people who are providing abortion services." (11) On this level, it is an effective strategy. A number of studies suggest that anti-abortion violence results in fear and stress among clinic staff. (12) These events form the basis for my third assertion, that abortion workers are employed in a context that is perceived by them (there is sufficient evidence to suggest that this perception is grounded in reality) to involve a significant degree of personal risk. This risk takes two forms: the fear and actual experience of physical harm and a pervading social stigmatization. (13) Each has a particular effect on workers, shaping their sense of workplace safety or lack thereof.

Although these assertions suggest that abortion services could be explored through established notions of workplace safety, there are two central problems with such an integration of analysis and practice. First, it is not easy to apply pre-existing concepts of workplace safety to abortion work. The models that many authors have developed to address health care workplace safety, though useful, are often concerned with patient violence, domestic violence that spills into the workplace, and random violence by the public. (14) These frameworks are cumbersome when trying to account for the ideology-based, systematic, and yet random threats and assaults by multiple unknown assailants. In other words, the pattern of violence that defines the working practices of people employed in abortion clinics is not easily understood within traditional notions of workplace safety.

The second barrier to applying notions of worker safety to abortion services relates to the ways in which abortion work is positioned in out society. A number of authors have drawn on Everett Hughes's sociological concept of "dirty work" to explain the ways that abortion is positioned as morally reprehensible. (15) Hughes describes "dirty work" as work that is defined by powerful others as morally reprehensible and work that society may require, but would prefer to avoid even thinking about. (16) Despite a long struggle to have abortion legalized and recognized as a valid medical procedure, it is still either hotly debated in moral terms or positioned in the shadows, discussed only in whispers. The inadequacies of language in discussing the specificity of abortion and the parallel construction of abortion as dirty work are mutually reinforcing. Our silence and the polarized moral debates about abortion increase the likelihood that it can be imagined as dirty work, which in turn manifests the silence and moral judgment. (17) These disjunctures between abortion work and workplace safety leave us clumsily considering a number of issues that, in turn, challenge us to find ways to rethink abortion work and notions of worker safety.

The silence that surrounds abortion work magnifies workers' insecurities and increases the isolation many of us feel in our jobs. It is not only the fear of physical violence that constitutes the hostile environment in which we work. It is also our fear of social stigma that regulates silence regarding abortion and subsequently leaves us dealing with our safety concerns alone. The pervasiveness of this stigma was never more evident to me than when the very women to whom we provided services expressed that they could not understand how we could be involved in this work; even some of the women who access abortion services consider it to be dirty work. Many abortion workers find it difficult, if not impossible, to tell friends, neighbours, and often even family members about our jobs. (18) Our vulnerability, and thus our constant heightened awareness that friends and neighbours might discover "what we do," is often a source of ongoing stress. (19) To illustrate, shortly after clinic staff received a fax confirming that pro-life groups had all of our names and addresses, my neighbours posted a sign in their front window with the slogan "justice for the unborn." I was completely unnerved, uncertain as to whether this was a statement for the general public or a message aimed directly at me. Each day I returned home from work to see the sign sitting there, unsure as to whether I needed to be concerned for my safety. It is these broader workplace hazards that make abortion workers' concerns even more difficult to contain within mainstream notions of worker safety. When the danger that originates in our workplaces slips incessantly into our private spheres, our ability to find ways to address these concerns within existing frameworks seems grossly inadequate. At the same time, perhaps the problems that abortion work presents provide an opportunity to consider the multiple ways in which many aspects of workers' safety fail to be contained within spaces of employment.

Another challenge in addressing the safety concerns of abortion workers is that the dangers faced by health care workers more generally have only been brought to light in the past decade or so. (20) Abortion workers' experience of verbal harassment, placard-carrying protesters, hospital staff placing various religious paraphernalia in the clinic, and staff silences and avoidances all serve to imbue our workplace with a virtual miasma of threat and uncertainty. We only have our first names on our nametags, we do not have names or titles on our office doors, the hallways surrounding our clinics have security cameras, and a security guard often sits at the front door of the clinic. Around Remembrance Day, which has, for a number of years, signaled an escalation in pro-life violence, we become increasingly cautious, particularly when using isolated parking spaces. The police have, at times, recommended that we vary our routes home. In this atmosphere of vague threats, perpetual caution, and little institutional or social support, our emotional responses are often difficult to organize in terms of paranoia versus legitimate caution, which also makes it difficult to discuss our work fears. Why should a pro-life bumper sticker on a car in the hospital parking lot raise my anxiety as I ride up the elevator? Then again, why should it not? This lack of a space in which we can confidently assess our fears as legitimate or otherwise ensures the silences regarding our work continue. We are left vulnerable and isolated.

The reluctance to explore the work of abortion workers and our safety issues is, moreover, a factor of the continued focus on patient safety; the patient's well-being is our primary concern while our own fears of violence shift to the periphery. We take care of the patients, but who is taking care of us? Although I do not suggest that patients should be anything but a priority, when this hierarchy of concern is situated within a context where much of women's caring labour is devalued, the issues faced by abortion workers fade into the background. (21)

What might be possible to consider within existing frameworks for debating worker safety is the broad restructuring of the health care system and the institutional structure in which many Canadian abortion clinics operate. The relationship between clinics and their parent hospitals has always been ambivalent. In 1995, Carole Joffe noted that even after the legalization of abortion services there was a significant degree of institutional resistance against their provision. (22) In today's neo-liberal economy, this relationship has the potential to become even more strained. For instance, hospitals increasingly rely on private donations as opposed to government funding; abortion services threaten those types of donations. If hospitals are forced to prioritize the acquisition of private funding, what will happen to the place of abortion services within the hospital system and what will these changes mean for patients and staff? Fiscal concerns have also resulted in an increase in part-time labour and the out-sourcing of services such as security, which presents new challenges to clinic staff who are often forced to depend upon less specialized security personnel who may know little about the specific safety concerns of abortion work. Shifts to the private sector often ignore the special needs of hospitals, particularly abortion clinics.

The dynamics that evolve from these new funding relations result in a less supportive workplace, and increase the need to keep one's work secret from other hospital staff. This atmosphere is further complicated as our roles change. We find that our jobs are becoming more rationalized and routinized, with an increased emphasis on technical aspects and less of a focus on caring and interpersonal relations. (23) Although many of us draw on the caring components of our practice to deflect our attention away from our fears and ambivalences, organizational pressures mean that "caring" has little significance in our overall work performance. These changes in health care are seldom considered in terms of their possible impact on abortion work, particularly in its location as dirty work. When workplace discussions increasingly focus on technicalities, our safety concerns seldom receive formal responses from hospital administrators or proactive preventative work from unions. Instead, safety issues are left largely in the hands of clinic staff. I think we seldom ever asked administration or union staff to become involved in our concerns because we had internalized the notion that violence, intimidation, and fear were "just part of the job" and that the priorities of our work were the technicalities (i.e. number of patients seen, hours worked, staff seniority, rate of complications among patients, etc.). We were probably also worried that raising our concerns would threaten what we perceived as our tenuous hold within the health care system. We would often speak about trying to stay quiet and under everyone's radar.

The changes in health care priorities will have a particular impact on the safety concerns of abortion workers. What will it mean to have part-time workers rotating through clinics? Will this type of employment structure not diminish the informal structures that offer staff security and safety? The caring component of our work is one of the few aspects that help workers negotiate its rather slippery moral terrain: if that falls away, what will be left? These are all significant aspects of considering worker safety. They are also the issues that concern all health care workers. How will health care restructuring affect our understandings of worker safety?

The ways in which our society responded to the anthrax concerns of postal workers as a general threat to Canadian workers is interesting when compared to our earlier responses to similar fears expressed by abortion workers. Our responses signify the cultural ambivalence we have toward health care workers who provide abortion services. (24) This is to the detriment of all workers, but particularly the nurses, social workers, ultrasound technicians, receptionists, security staff, housekeeping staff, and physicians who are struggling through the day-to-day safety issues involved in abortion work. Unless we begin to find ways to explore abortion work from the perspective of workplace safety, the important issues that are facing these workers will continue to be ignored. Abortion work is principally a regular health tare service carried out, for the most part, by unsupported health care providers in an extraordinarily hostile environment. At a time of enormous transition within the health tare system, and in our current heightened sense of insecurity, it is important that the uneasiness of these workers be recognized as credible concerns for workers in general.

(1) British Columbia Premier Gordon Campbell as quoted in "Anthrax Tests for Three B.C. Workers," Toronto Star, 25 October 2001.

(2) Scott Simmie, "Canadians Cope with New Fears," Toronto Star, 29 October 2001.

(3) For example, information regarding the threat that anthrax can pose to workers has, since the autumn of 2001, appeared on the Ontario Public Service Employees Union website <http://www.opseu.org/hands/anthraxfacts.htm> (22 July 2003), and on the Canadian Centre for Occupational Health and Safety (CCOHS) website <http://www.ccohs.ca/headlines/text88.html> (22 July 2003). Both organizations confirm that these web pages were developed in anticipation of receiving inquiries this past autumn. Though the CCOHS web site has recorded thousands of visits, an inquiries officer confirmed that "[anthrax] has not been the subject of many work-related inquiries--one in 1998 and another in 1995!" Huguette Nadeau, Inquiries Officer, personal communication, 29 January 2002.

(4) It is difficult to find statistics that have not been worked into one side or the other of the abortion debate. The National Abortion Federation has documented 630 anthrax threats across clinics in the United States and Canada. See <http://www.prochoice.org/Violence/Statistics/default.htm> (22 July 2003). Any number of internet websites will suggest that either abortion clinics are fabricating the threats made against them or, alternately, are violent and threatening toward pro-life groups. Therefore, I use statistics to document, if nothing else, the perception of danger and threat into which the daily practices of abortion workers are embedded.

(5) Marianne Such-Baer, "Professional Staff Reaction to Abortion Work," Social Casework, 55 (July 1974), 435-41; Cherilyn van Berkel, "Abortion Work: Health Care's Best Kept Secret," MSW project, McMaster University, 2001; Catherine Chiappetta-Swanson, "The Process of Caring: Nurses' Perspectives on Caring for Women Who End Pregnancies for Fetal Anomaly," PhD dissertation, McMaster University, 2001.

(6) For instance, van Berkel spoke to a hospital technician who suddenly found her job had expanded to providing ultrasounds to women before they terminate their pregnancies. This practice ensures that medical staff know the exact gestational "age" of the fetus. See van Berkel, "Abortion at Work."

(7) This type of approach to the work has been noted in various studies, see Cherilyn van Berkel, "Abortion at Work," and Chiapetta-Swanson, "The Process of Caring."

(8) Since 1977 the National Abortion Federation has documented violence against abortion clinics. This has included 7 murders, 17 attempted murders, 41 bombings, 165 arsons, 82 attempted arsons and bombings, 122 assaults, 950 acts of vandalism, 343 death threats, 3 kidnappings, 100 butyric acid attacks and, as already noted, 630 anthrax threats see National Abortion Federation, "2001 Table: Incidents of violence and Disruption Against Abortion Providers," <http://www.prochoice.org/Violence/Statistics/default.htm>.

(9) On 11 July 2000 Dr. Romalis was also stabbed as he walked through the lobby area of the office building where he worked. Dr. Romalis was not fatally injured.

(10) For example, in 1991, in Springfield, MO, a clinic receptionist was shot and paralyzed from the waist down. A nurse and security guard were also killed in the 1998 bombing of a Birmingham, AL, clinic.

(11) "Abortionist Says Doctors Can't Abandon Women," Toronto Star, 14 November 1997.

(12) In W. Simmond "Feminism on the Job: Confronting Opposition in Abortion Work," in Myra Marx Feree and Patricia Yancey Martin, eds., Feminist Organizations: Harvest of the New Women's Movement (Philadelphia 1995) one worker suggested that the work they were doing following a rather prolonged period of pro-life protests was like, "what it must have been like for soldiers in the war" (255). For a discussion of some of the effects that "harassment" has had on clinics in Ontario, see Lorraine Ferris, Margot McMain-Klein, and Karey Iron, "Factors Influencing the Delivery of Abortion Services in Ontario: A Descriptive Study," Family Planning Perspectives, 30 (June 1998), 134-8.

(13) Simmonds "Feminism on the Job"; and B. Major and R.H. Gramzow, "Abortion as Stigma: Cognitive and Emotional Implications of Concealment," Journal of Personality and Social Psychology, 77 (October 1999), 735-45.

(14) Dorothy Wigmore, "'Taking Back' the Workplace," in Karen Messing, Barbara Neis, and Lucie Dumac, eds., Invisible: Issues in Women's Occupational Health (Charlottetown 1995); Beverly Younger, "Violence Against Women in the Workplace," in Employee Assistance Quarterly, 9 (Spring-Summer 1994), 113-33.

(15) The notion of dirty work is present in Carole Joffe's "Abortion Work: Strains, Coping Strategies, Policy Implications," Social Work, 24 (November 1979), 485-90; Chiappetta-Swanson, "The Process of Caring." However, this use of the concept is somewhat problematic in that Hughes develops it from thinking through how ordinary Germans stood by while the Nazis murdered six million Jewish persons and how American and Canadian societies said little about the internment of the Japanese.

(16) Everett Hughes, The Sociological Eye: Selected Papers (Chicago 1971).

(17) When a postal worker receives an anthrax threat, we can all imagine ourselves being vulnerable and can identify the issue as one of general concern to workers. On the other hand, when abortion workers raise similar concerns, we prefer not to identify with these workers. We (including much of the media) avoid the issue and certainly do not generalize abortion workers' fears to all workers.

(18) Interestingly the "outing" of abortion providers, workers, and women seeking abortions bas been a strategy of intimidation used by certain pro-life groups. Given the cultural ambivalence and often-hostile context in which abortion services are provided, the threat of having one's name or photograph posted in the internet presents a significant threat.

(19) Chiapetta-Swanson, "The Process of Caring; and van Berkel, "Abortion at Work."

(20) Jane Lipscomb and Colleen Love "Violence Toward Health Care Workers: An Emerging Occupational Hazard," American Association of Occupational Health Nurses (hereafter AAOHN), (May 1992), 219-27; Sally Lusk, "Violence Experienced by Nurses' Aids in Nursing Homes: An Exploratory Study," AAOHN, (May 1992), 237-41; Wigmore, "'Taking Back' the Workplace."

(21) See Sheila Neysmith, "Networking Across Difference: Connecting Restructuring and Caring Labour," in Sheila Neysmith, ed., Restructuring Caring Labour: Discourse, State Practice, and Everyday Life, (Don Mills, Ontario 2000), 1-28.

(22) Carole Joffe, Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe vs. Wade (Boston 1995).

(23) Marie Campbell, "Knowledge, Gendered Subjectivity, and the Restructuring of Health Care: The Case of the Disappearing Nurse," in Neysmith, Restructuring Caring Labour, 186-208.

(24) Interestingly, in my e-mail conversation with an Inquiries Officer at the Canadian Centre for Occupational Health and Safety, the only "legitimate" concern for anthrax poisoning was the threat it poses "for workers exposed to infected animals (or contaminated carcasses or hides)" Personal communication with Huguette Nadeau, Inquiries Officer, CCHOS.