The Precarious Work of Care: OSHA, AIDS, and Women Health-Care Workers, 1983–2000

This article examines a series of Service Employees’ International Union (SEIU) campaigns for protection from needlestick injuries, led by women health-care workers, from the dawn of the HIV/AIDS epidemic in the 1980s through battles over the 1992 OSHA standard on blood-borne pathogens and the Needlestick Safety and Prevention Act of 2000. We argue that these campaigns developed in response to the growing physical precarity of women health-care workers in the era of “managed care,” caused by the intensification and flexibilization of health-care labor and the deregulation and underfunding of OSHA and the CDC. We show how women workers challenged employers, OSHA, and elected federal officials to address workplace health hazards, through unions like SEIU and women’s, gay rights, and public health organizations. More broadly, we argue that the occupational hazards of health-care workers are a crucial but underexplored facet of workplace studies and the history of women workers in the late twentieth and early twenty-first centuries.

When Peggy Ferro testified before Congress in February 1992, she had been living with HIV for nearly two years. Appearing under the pseudonym “Jean Roe,” Ferro was addressing a House subcommittee hearing on the new Occupational Safety and Health Administration (OSHA) standard on blood-borne pathogens. She argued that the proposed OSHA standard was fatally flawed. Because it failed to mandate the use of safer needles, connective devices, and IV lines in hospitals, it would not prevent health-care workers like her from being infected with HIV, Hepatitis B (HBV), and other blood-borne pathogens. A certified nursing assistant since 1969, Ferro worked “at a major private hospital in San Francisco”; but she only could speak confidentially due to her concerns about employment discrimination. “I am a health-care worker who is now HIV infected from a needlestick injury,” she testified. “This is a documented occupational transmission.”¹

Ferro explained how she acquired HIV on the job in 1990, while she was cleaning a patient’s bedside table. “The patient was newly admitted to my unit and was medically unstable,” she recalled. “My first priority was my patient’s medical status — stabilizing his condition and keeping him alive. That night, I was also responsible for two other patients, one of whom was also medically unstable. I was trying to cope with a very heavy patient case load.” Concerned for her patient, she “was exposed to an unprotected needle with enough HIV-contaminated blood to infect [me] and to change [my] life forever.” Casting doubt on existing statistics on occupational HIV exposure, Ferro pointed out that, because her disease had not yet progressed into “full-blown AIDS,” the Centers for Disease Control (CDC) HIV/AIDS Surveillance Report ignored her case, as it did others like it.² There were, however, many infected health-care workers like her. At the time, an estimated 1 million accidental needle-sticks occurred every year in the United States. They resulted in some three hundred deaths annually from HBV among health-care workers and an unknown but increasing number of occupational HIV infections.³ Indeed, the scale of the problem was almost certainly larger, since most needlesticks went unreported.

Peggy Ferro died of AIDS in 1998. Beyond recovering her largely forgotten story and those of other health-care workers like her, this article places Ferro’s life in a larger historical context. We focus on three issues that Ferro emphasized in her testimony. The first is the precarious nature of women’s work in the health-care industry, not just in terms of flexible employment, but also of the bodily risks women face on a daily basis, a fact made powerfully evident in the 2020 coronavirus pandemic. The occupational hazards of health-care workers are a crucial but underexplored facet of workplace studies and the history of women workers in the late twentieth century. Between 1970 and 1983, the number of health-care workers increased over 80 percent to nearly 8 million. Stratified both by gender and race, nurses and direct care givers are disproportionately female; and those employed as health-care aides and in hospital food and janitorial service were and are disproportionately workers of color. By the 1990s, for example, 85 percent of health-care workers in hospitals were women, while 80 percent of physicians were men. Ferro, who was white and a shop steward in SEIU Local 250, worked in an increasingly precarious environment in this period.⁴ As Ferro explained in her testimony, she contracted HIV because her employer failed to purchase safer needles but also because of an excessive patient case load that forced her and other workers to cut corners on safety.⁵ The intensification of care labor, especially among women health-care workers, must be placed in the context of the rise of managed health care and the restructuring of care work in the late twentieth century.⁶

Second, in her testimony, Ferro drew attention to the failure of both OSHA and the CDC to adequately address the health risks facing women workers. Occupational health research has long privileged catastrophic injury over chronic disease, and workers’ compensation boards routinely grant substantially more and greater compensation awards to workers with occupational injuries than to those who contract diseases in the workplace.⁷ OSHA’s original mandate focused on the construction trades and manufacturing work, and the hazards of heavy machinery, dust, and chemicals were its chief concerns.⁸ Moreover, OSHA has been underfunded and understaffed from the beginning, and the deregulation of the Carter and Reagan years weakened the agency further. Thus, the daily exposure of health-care workers and others to biological hazards was outside of the central concerns and resources of OSHA and the CDC, both of which faced shrinking budgets and hostility from the White House and Republicans in Congress.

Occupational exposure to HIV/AIDS provides a particularly vivid example of these larger problems. In the 1980s, the disease was the subject of a wide-ranging and sometimes panicked debate in health-care and policy circles. Beyond focusing on its etiology and course, health-care workers, medical researchers, and hospital administrators argued about the forms of HIV transmission, the treatment of the disease, and the appropriate medical and social response to the growing HIV/AIDS epidemic. The first widely discussed case of occupational transmission stirred controversies about how to control the risks both patients and health-care workers faced, even as doctors and administrators proposed mandatory testing of surgical patients and health-care workers and advocated the use of hazard suits in emergency rooms. Although the number of health-care workers who contracted HIV on the job remained small — almost all of them through accidental needlestick injuries — they played a pivotal role in labor unions’ struggle to protect health-care workers from blood-borne pathogens in the 1980s and 1990s, an effort in which the Service Employees’ International Union (SEIU) played a major role.⁹

In many ways, nurses’ contraction of HIV from needlestick injuries exposed the contradictions in occupational health-care policy and in the political response to AIDS. Women health-care workers and their unions struggled to respond to the threat of occupational exposure in the context of the Reagan administration’s hostility to OSHA and its resistance to federal funding of HIV/AIDS research. More important, economic restructuring in the health-care industry and the rise of managed care led to higher workloads, increased stress, and employer resistance to the adoption of new, costlier medical equipment, no matter how safe. This leads to the third theme of Ferro’s testimony: how women workers and their unions challenged employers, OSHA, and elected federal officials to address workplace health hazards through unions like SEIU and through women’s, gay rights, and public health organizations.¹⁰

First we focus on the emergence of needlestick injuries in health care and their linkage to blood-borne pathogens and the occupational transmission of HBV and, later, HIV/AIDS. Second, we examine the SEIU campaign against occupational HIV transmission, from the union’s first AIDS Education Committee in 1983 to its lobbying efforts to secure and implement an OSHA standard on blood-borne pathogens from 1987 to 1992. Third, we trace SEIU needlestick campaigns through the year 2000, which led to the implementation of state-level needlestick prevention laws and, ultimately, the passage of the federal Needlestick Safety and Prevention Act. The SEIU campaigns took place in the context of massive economic restructuring in the health-care industry and the ongoing opposition of conservative politicians and business lobbying groups to strong OSHA enforcement. The passage of the Needle-stick Safety and Prevention Act, which went much further in protecting health-care workers than the OSHA standard did, was a major achievement against steep odds. Finally, we ask how examining occupational health and safety in the increasingly precarious work of health care contributes to our understanding of workplace conditions and policies. As long as blood-borne pathogens remain the single major occupational hazard in the health-care industry, its workers remain on the front line of occupational health and safety battles today.

AIDS and the Fight for an OSHA Blood-Borne Pathogen Standard, 1983–1992

For most people, the phrase occupational hazard brings to mind blue-collar men, not women; heavy industry and not service work.¹¹ By the 1970s, with the shift to a new service economy and the influx of new women and minority workers into the labor force, commonplace ideas about work and workers were increasingly outdated. Moreover, the primary association of dangerous work with white men in mining, manufacturing, and construction obscured the work experience of women and minorities in workplaces and jobs that entailed new risks. There, workers encountered tasks, technologies, and locations that were objectively, if incidentally, more dangerous. In the decades since the Occupational Safety and Health Act (OSHA) was passed in 1970, unions like the SEIU and the American Federation of State, County, and Municipal Employees (AFSCME) have aggressively and effectively lobbied for new OSHA standards to protect their disproportionately female and minority members, many of whom worked in the public and health-care service sector.

In the 1970s and 1980s, at a time when most industrial unions were losing membership, the SEIU was expanding. Its success was due less to organizing new members than to President George Hardy’s reach-out strategy of affiliating with and incorporating smaller independent unions. Such mergers added 230,000 members to SEIU between 1971 and 1985, bringing the total membership to roughly 635,000. Between 1980 and 1984, under President John Sweeney, the SEIU gained another 160,000 members through four more mergers.¹² In the process, SEIU absorbed hundreds of thousands of members in the health-care industry, including nurses, health and human services workers, and hospital staff. As a result, the union became one of the leading advocates of new occupational safety measures and a central force in the fight for an OSHA standard on blood-borne pathogens.¹³

One of the larger locals within SEIU was Local 250, representing some 30,000 workers in the Bay Area, including San Francisco General Hospital (SFGH) in the Mission District.¹⁴ Between 1986 and 1992, Local 250 members played a key role in lobbying for the passage of OSHA’s blood-borne pathogen standard. First, LGBT health activists, some of whom were SEIU members, already were addressing the dramatic spread of HBV, especially in the gay community. Before it was known that Hep B could be spread through sexual as well as blood transmission, gay health clinics were diagnosing and treating it. Preexisting health-care resources and networks helped to generate a response when a new disease — HIV — emerged as an issue in 1981.¹⁵ San Francisco General led the nation in the diagnosis and treatment of HIV/AIDS. Local 250’s location at the epicenter of the HIV/AIDS epidemic presented the union with opportunities to lead on the issue. Although HBV was a much greater threat to health-care workers than HIV was, the national AIDS crisis heightened public sensitivity to the dangers of blood-borne pathogens and provided unions (chiefly SEIU and AFSCME) with political leverage at a time of retrenchment for organized labor and social regulations. While HBV remained below the radar, a pervasive but largely invisible danger, health-care workers benefited from the public attention to, and measures to prevent, HIV/AIDS.¹⁶

By the early 1980s, the prospects for lobbying OSHA to better protect the nation’s health-care workers were not bright. From its origins, the agency was embattled and underfunded. During the Nixon and Ford administrations, OSHA pursued a cautious policy of targeting small businesses for oversight, rather than large corporations. In its first three years, it developed only three standards — for asbestos, vinyl chloride, and a “package” standard for fourteen carcinogens. While OSHA established standards for industrial hazards such as dust, pesticides, heat stress, and coke oven emissions, inspectors focused on trucking, construction, and heavy-industrial firms.¹⁷ Sociologist Kathryn Ratcliff observed, “OSHA has, since its inception, paid special attention to the hazards of the construction site and of heavy industry, both of which are male-dominated occupations.” It all but ignored sectors of the workforce that were predominantly female, except in the case of reproductive hazards; above all, it neglected the health-care industry.¹⁸

Under the leadership of Carter appointee Eula Bingham, OSHA began to ramp up inspections and enforcement, set new workplace standards, and expand education for workers on occupational safety. Still, the economic downturn of the 1970s and aggressive counterattacks from industry pressured the Carter administration to limit regulation and enforcement.¹⁹ It adopted cost-benefit criteria for OSHA standards, which Carter’s Regulatory Analysis and Review Group inaugurated in 1978. In 1981, the incoming Reagan administration further weakened enforcement. Committed to government deregulation, it replaced the heads of OSHA and the National Institute for Occupational Safety and Health (NIOSH) with appointees more aligned with the private sector. It then cut the funding and staff at both agencies and folded the latter into the CDC. Under new leadership, OSHA emphasized consultation with employers rather than with labor unions, and voluntary guidelines rather than mandatory workplace inspections and penalties.²⁰

At the time, the American health-care system was undergoing what historical sociologist Paul Starr has labeled a “dramatic corporate expansion.”²¹ As national health insurance receded from the policy-making horizon, regional health-care conglomerates, organized under the aegis of managed care, captured an ever-greater share of the hospital services market. Managed care providers typically instituted cost-cutting measures that increased workloads for hospital staff and resisted implementing new safety technologies. Rising patient-to-nurse ratios placed greater strain on nurses and other health-care workers, which often led to higher incidence of workplace stress and injury.²²

Between 1981 and 1993, the number of bedside nursing caregivers at hospitals in the United States declined 7.3 percent, even as managed care providers increased the patient-to-nurse ratio.²³ In 1983, the federal Medicare program began paying hospitals a flat rate for treating patients based on diagnosis, rather than patient services. A study of hospitals in the San Francisco Bay Area found that this change in Medicare policy inaugurated a new “era of managerial control and market mechanisms” that encouraged increased caseloads.²⁴ Exposure to blood-borne pathogens and diseases such as AIDS thus arrived on the epidemiological scene at a time when health-care workers were under increasing job stress even as the federal government retreated from OSHA’s original mandate to protect all workers from occupational hazards.

Members of SEIU Local 250, especially those at SFGH, were well-positioned to appreciate how social and political forces made them more vulnerable to occupational health risks. Unions like SEIU and AFSCME were acutely aware of increasing occupational exposure to blood-borne pathogens, especially HBV. The most common form of occupational transmission for HBV was accidental needlestick injuries, a daily occurrence in the nation’s hospitals. According to OSHA, only 1 percent of hospital health-care workers annually were infected; but medical staff in emergency rooms, surgery, pathology, and IV teams had a significantly higher long-term risk of exposure of from 15 to 30 percent. These risks were only mitigated by vaccination and safe work practices.²⁵ A study of the University of Wisconsin Hospital from 1975 to 1979, for example, found that the average annual rate of accidental needlesticks was 92.6 per thousand among nurses and 127 per thousand among housekeeping and maintenance staff.²⁶

Although an HBV vaccine came on the market in 1981, most health-care employers were not willing to pay $100 or more per worker for a series of vaccine shots.²⁷ Many health-care workers were unaware of the vaccine, and even those who were aware could not always afford it. The result was that vaccination rates lingered below 5 percent through the 1980s. In 1983 alone, an estimated 17,000 health-care workers contracted HBV from occupational exposure; an average of 300 died from such exposures annually.²⁸

In 1983, OSHA distributed a set of guidelines to health-care industry employers, “designed to reduce the risk of occupational exposure to Hepatitis B virus.” The guidelines included a description of the disease and recommendations for use of the new HBV vaccine.²⁹ In keeping with Reagan-era policy, the guidelines emphasized voluntary compliance, rather than mandatory standards. In practice, “voluntary” meant that health-care employers continued to deny HBV vaccination to their employees. Many health-care workers and union activists recognized that OSHA’s measures were wholly insufficient, both for the purposes of education and in regulating labor practices. In effect, it meant that HBV remained a major occupational risk.

By 1981, the emergence of HIV/AIDS, a virus transmitted through blood, increased the visibility and the stakes for health-care workers exposed to newly diagnosed pathogens. Doctors at SFGH established a clinic to treat patients with the new, mysterious immunological disorder that appeared in gay male patients in cities from Miami to Los Angeles. Initially called Karposi’s Sarcoma/Opportunistic Infections Clinic, this unit of the SFGH began treating patients in August 1981.³⁰ At the time, epidemiologists were calling the disorder Gay-Related Immune Deficiency; a year later, the CDC coined the term Acquired Immune Deficiency Syndrome (AIDS).³¹ Located in one of the epicenters of the crisis, SFGH became the nation’s first hospital with a specialized HIV/AIDS clinic; it also became the leader in addressing the risks for occupational transmission of the disease.

As the HIV/AIDS epidemic became more visible, several members of SEIU Local 250 formed an AIDS Education Committee (AEC). Already there was widespread misinformation and fear about the disease, even — or perhaps especially — in the health-care community.³² In response, the AEC produced a brochure entitled AIDS and the Healthcare Worker to educate workers about the risks of occupational exposure and AIDS discrimination issues. AEC conducted educational workshops for union stewards and hospital staff. By 1990, AIDS and the Healthcare Worker had gone through five editions, and SEIU had distributed hundreds of thousands of copies in the United States and around the world.³³

Early on, SEIU members realized that union educational efforts were not enough to protect health-care workers from AIDS.³⁴ The union’s longstanding concerns about HBV transmission shaped their response to the new biological threat. This is not surprising. AIDS was not yet a documented occupational disease, while HBV continued to claim the lives of hundreds of health-care workers annually. Only the federal government, issuing an OSHA standard for blood-borne pathogens, had the power to compel the nation’s health-care employers to adopt stronger measures to control exposure and reduce risks of contracting the disease.³⁵ In 1983, SEIU President John Sweeney wrote a letter to the American Public Health Association announcing SEIU’s campaign for a new standard. Alluding to the limitations of voluntary guidelines, Sweeney wrote, “We will petition OSHA to reinforce its correct advice with a clear directive that employers must pay” for an HBV vaccine.³⁶ HIV/AIDS and HBV became linked causes in the struggle for a safer health-care workplace.

SEIU understood the power of that linkage. SEIU Health and Safety Director Bill Borwegen believed that public fear of AIDS could provide the support needed for a blood-borne pathogen standard.³⁷ He founded the SEIU’s Health and Safety Department in 1983 and was centrally involved in the campaign for an OSHA blood-borne pathogen standard from 1986 to 1992. In choosing to emphasize the threat of occupational HIV, Borwegen’s logic was pragmatic. Reagan administration officials were hostile both to unions and to the regulation of businesses — a hostility they extended to issues of health and safety. They would be hard-pressed, however, to reject safeguards against a terrifying, mysterious national epidemic. Moreover, the AIDS crisis, as much as it generated widespread fear of contagion, had the potential to forge new and more powerful activist coalitions.

In September 1986, SEIU and AFSCME sent petitions to OSHA demanding the replacement of voluntary guidelines for blood-borne pathogens with mandatory standards. Union leaders discovered quickly that OSHA officials were not sympathetic. Reagan’s assistant secretary of labor for OSHA, John Pendergrass, was reluctant to classify infectious diseases as occupational hazards. Union leaders had to take their petitions to Congress, which resulted in hearings instigated by congressional Democrats, including Tom Lantos (D-CA) and Edward Kennedy (D-MA). While the first hearing, “Need for Immediate OSHA Regulations to Protect Health Care Workers from AIDS,” reflected the urgency of the AIDS epidemic, SEIU leaders continued to see HBV as the paramount occupational health hazard facing health-care workers. Several high-profile cases of occupational HIV transmission that year underlined that urgency and reinforced SEIU’s focus on AIDS as the more immediate threat to health-care workers.³⁸

During the hearings, OSHA and the CDC came under fire from congressional Democrats, union activists, and physicians for what Congressman Lantos called the “glacial” pace of standard setting in the health care industry. OSHA staffer Susan Harwood risked her career by speaking out against Pendergrass and other Reagan appointees, whom she charged with deliberately stalling. By continuing to allow health-care providers to deny their employees HBV vaccinations, OSHA was at least partly responsible for what were, by its own calculations, between 167 and 202 annual health-care worker deaths from occupational HBV exposure.³⁹ These deaths, along with the new threat of occupational transmission of HIV, were powerful motivations for OSHA to act.

OSHA did not publish its Notice of Proposed Rulemaking until 1989, several months after the hearings ended. Only two years later did it issue the blood-borne pathogen standard. More than ten years after the AIDS epidemic broke in 1981, and five years after the SEIU and AFSCME campaigns began, OSHA’s blood-borne pathogen standard mandated HBV vaccinations, an important step in the nationwide battle against HBV. As medical historian William Muraskin observed in a 1995 article, the 1992 standard was a “very far-reaching one and encompassed most, though not all, of what the unions sought.”⁴⁰ Yet, the standard fell short in one crucial respect: it failed to mandate the safer needles that would have protected workers like Peggy Ferro.

Indeed, for health-care workers on the front lines of the HIV and HBV epidemics, the omission was a glaring one. OSHA’s failure to mandate engineering controls (or safer design standards for needles and connective devices) left millions of health-care workers at risk from blood-borne pathogens. Nurses, health-care workers, emergency medical technicians, and even medical residents remained at risk of HIV and HBV infections. Whatever immediate clarity the standard brought, the continued exposure of health-care workers to sharps injuries necessitated unions advocate in support of new technologies that would reduce workers’ exposure and risk. In many ways, the SEIU’s work collecting information, educating the public, and lobbying for safety devices finally forced the issue.

Needlesticks and Women Health-Care Workers’ AIDS Activism: The Case of Jane Doe

In July 1987, a twenty-five-year-old nurse at SFGH named Mary Magee was changing a patient’s needle in the HIV/AIDS ward. The needle, unsheathed and filled with blood, was used to connect the patient’s IV tubing to heplock tubing. As she later recalled, the ward was crowded. The nearest sharps disposal container was located on the other side. Before she could safely dispose of the needle, she accidentally stuck herself with it. She was tested several days later as HIV-negative. A follow-up test in September, however, showed that she was HIV-positive.⁴¹ As she later noted, “It felt like a death sentence.” Further, it was, as later reported, “like a bucket of ice to the face,” for nurses who had been “determined to prove there were no excessive dangers associated with working with HIV-positive patients.” As nurse and activist Diane Jones later recalled, “I had probably 10 needle sticks in the first four years of being a nurse, and we wore these exposures like notches on our belts. . . . What [Magee’s] exposure did was cut through all of our denial. It made me a better nurse and certainly a better advocate.”⁴²

Still, Magee found herself with a dilemma. She did not want to lose her job or to sacrifice her career. If she went on workers’ compensation, it would reveal her disease status to her coworkers and to the larger medical community. Fearing discrimination in employment, insurance, and in treatment, Magee engaged in a two-year struggle with the California Workers’ Compensation Board to grant her workers’ compensation while keeping her name and condition private. She only revealed her name publicly more than twenty years later.⁴³

Like other workers who contracted HIV, Magee was faced with escalating medical costs. The antiviral medications that protected her life and extended her health amounted to thousands of dollars per year. To the costs of treatment were added lost work days and pay as Magee, like other workers, took sick days to recover from the flu-like symptoms of seroconversion. Despite the difficulty in receiving an award, workers’ compensation only partially paid for the costs of contracting HIV on the job.⁴⁴ Meanwhile, Magee participated in SEIU AIDS education workshops under the name Jane Doe. She and other nurses and health-care workers organized and lobbied for improved medical equipment, confidentiality as a guard against discrimination, and new safety standards that might reduce the risks of contracting HIV on the job. Magee later testified before Congress about the conditions of her injury and what might have prevented it.⁴⁵ Other union members testifying in state and congressional hearings used the story of Jane Doe to illustrate the dangers of standard needles.

Magee was not the first health-care worker to become occupationally infected by HIV. The CDC’s May 22, 1987, Morbidity and Mortality Weekly Report provided several case reports of health-care workers who became HIV-positive after exposure to infected blood. One of them, “a female phlebotomist,” was infected when the top of a 10-millimeter vacuum blood collection tube “blew off and blood splattered around in the room, on her face and in her mouth.” Another, a female medical technologist, was infected by blood spilled on her arms and gloveless hands, although she had no visible open wounds. By 1989, the CDC estimated that twenty-two health-care workers with “no other risk factors” had become HIV-positive from occupational exposure. Many medical professionals called that figure overly conservative.⁴⁶

Magee’s case played an important role in the SEIU campaign. As Lorraine Day, the chief orthopedic surgeon at SFGH, testified at a congressional oversight hearing on OSHA, “the Centers for Disease Control have told us over and over again that the risk of a health-care worker contracting AIDS from occupational exposure is low. I believed that until October 2, 1987, when a woman nurse at our hospital turned HIV positive from one needlestick on the job.”⁴⁷ By 1989, Magee was only one of numerous health-care workers who suffered from occupational HIV transmission from accidental needlestick injuries. As other state and federal hearings would show, health-care workers faced significant risks and substantial consequences for accidental injuries that endangered their livelihoods, their health, their relationships, and even their lives. “In every case,” as nurse activist Lorraine Thiebaud later declared, “epidemics are solved — not simply through science — but through political will.”

“We Must Prevent Further Needlestick Injuries from Destroying Other Lives”

Over the next three years, OSHA scheduled hearings in Washington, DC, New York, San Francisco, and Miami. As OSHA officials drafted the final standard, with what seemed an agonizing slowness to many observers, needlestick HIV transmissions continued to accumulate. Two cases played a particularly important role in the SEIU campaign. The first concerned Peggy Ferro, the certified nursing assistant whose case became a major focal point of the hearings. Speaking as “Jean Roe,” she presented her testimony to campaign for engineering controls — more specifically, safety syringes and other blood-collection devices — in the health-care workplace. Being “told by management to be more careful,” she testified, “is meaningless when you are working 12- to 16-hour shifts, being called in early, carrying double patient loads, and facing a shortage of trained staff.” Ferro forcefully argued, “The technology was available in 1990 to prevent my needlestick injury. At that time, my hospital did not use safer needle-bearing devices. I am now infected. Unsafe medical devices must be taken off the market and medical facilities instructed to choose the best available technology on the market.”

Ferro gave her testimony after OSHA’s blood-borne pathogen standard had been drafted. The standard lacked both employer incentives and sufficient penalties. As it was passed, the standard offered little recourse to workers like Ferro. In effect, she explained, the campaign to meaningfully implement the standard, then led by SEIU and its community allies, had to continue until engineering controls were put in place.⁴⁸

The second case involved Janet Christensen, a registered nurse at SFGH, who testified after Ferro. Christensen was not anonymous, because she had not been infected with HIV. Instead, she had accidentally infected a medical student with HIV while he was standing at her patient’s bedside in 1991. Christensen explained that as she was withdrawing an HIV-infected needle from a patient’s vein “the medical student’s free hand swung back and hit the contaminated stylet on the fleshy, palm side of his hand.” The incident would not have occurred, she believed, if the AIDS clinic had been equipped with another product, the “self-covering Critikon angiocath,” which was standard issue in the SFGH emergency room at the time.⁴⁹

As these cases show, the OSHA standard was of limited use in preventing the over one million accidental needlesticks in the nation’s hospitals that occurred every year. Its guidelines advocated cultivating workplace safety practices but offered little support for upgrading and improving technologies for delivering medication or the drawing or transfusion of blood. Moreover, six years after the passages of the standard, OSHA inspectors carried out only 200 inspections of health-care facilities to enforce it. Given widespread underreporting of needlesticks and the lack of mandatory engineering controls, health-care employers had every incentive to continue selling lower-cost needles. It would take another decade of activism, led by SEIU members like Magee, Ferro, and Christensen, to win more effective legislation.

Corporate Medicine and the Struggle for Needlestick Legislation, 1992–2000

Establishing a blood-borne pathogen standard answered the need to deal with HBV infections, but it did little to change conditions that created more than 800,000 reported needlestick injuries per year or the specific risk of contracting HIV after an accidental sharps puncture. Changing work practices and advocating the use of safer needles or needle-free blood-collection devices were the main paths by which nurses and other health-care workers could reduce the epidemic of injury in the health-care workplace.

Implementing such practices in corporate hospital systems, however, was and is beyond the power of health-care workers, even when unionized. When OSHA introduced the new blood-borne pathogen standard, it was unprepared both in terms of the complexity of the problem and for the resistance of the health-care industry. As health reporter Karen Pallarito noted, the agency lacked experience in health-care workplaces. Its inspectors were not “as familiar with terminology and protocols in the hospital industry as they [were] with factories, mills, packing plants and other businesses.” Implementing the blood-borne pathogen standard was of necessity different from limiting chemical exposures or machine hazards. Elizabeth Sommers Strevey, a senior vice president of the New York Hospital Association, reported that it was not a “classical environment in which OSHA functioned; at least one inspector had to have ‘phlebotomy’ explained.” OSHA also lacked the authority to order widespread adoption of safer health-care equipment. Its failure to adequately regulate or inspect health-care facilities and to require the use of engineering controls, and inadequate inspector training, meant the new standards were not sufficient. New biological hazards, as one industry expert noted, seemed to call for “a massive increase in inspectors, inspections, and fines.”⁵⁰ In addition, new chemicals, such as those used in chemotherapy; new technologies in the health-care workplace; the weakness or absence of collective bargaining agreements; and the continued and intensifying pace of work in hospitals and other care units further undermined the safety of health-care workers, both within and outside of hospitals.⁵¹ What was needed was a federal law, not a voluntary standard.

Hospitals, health-care providers, and medical equipment manufacturers, among others, lobbied strongly against change and resisted widespread demands for safety needles. Their argument rested on cost-benefit analysis. HIV transmission and seroconversion were relatively rare, constituting only a small percentage (1–2 percent) of all needlestick injuries. Safer equipment, they pointed out, was more expensive. Phlebotomy needles cost only 10 cents for a conventional device but 33 cents for a safer version. Implementing that one change could cost a 250-to-300-bed hospital $15,000 a year. Shifting to safer butterfly needles would cost an additional 25 cents per needle, or $4,000 a year for an average hospital. For an IV, the improved catheter cost $1.00 more per unit, or $33,500; for a hypodermic syringe, 20 cents, or $67,000 per year for the same hospital. Hospital leaders argued that there was both increased unit costs for the new devices and staff resistance to their implementation. There were problems with compatibility and with prior medical equipment contracts.⁵² As late as 2000, union representatives complained about OSHA’s failure to address the rising tide of needlestick injuries. Bill Borwegen, SEIU health and safety director, declared it a “no-brainer” to require safer needles for use in health care. State legislatures, he continued, were “left with the impression that [OSHA] is out of touch and incapable of tackling one of the more glaring, clear-cut and readily addressed occupational health hazards confronting workers in one of the fastest growing sectors of the economy.”⁵³

In 1998, six years after the OSHA standard was adopted, William Charney, health and safety officer at SFGH, simply said, “When you look at the rate of needle sticks, the (OSHA) standard hasn’t done squat.” That year, the San Francisco Chronicle ran a series of articles on the issue, documenting in a timeline failed efforts to reduce the risk of needlestick injuries among health-care workers and the persistent opposition to paying for safety needles and other engineering controls. At an international conference, Dr. Janine Jagger argued that “safety [was] viewed as an optional market opportunity (for manufacturers), of interest only if potential profits appear[ed] higher than those earned from conventional, hazardous technology.”⁵⁴ Still, in April of 1998, the Chronicle reported, OSHA’s blood-borne pathogen standard left the 8.8 million health-care workers at risk. Among the more than 1 million accidental needlesticks in the workplace a year, thousands would contract Hepatitis C (HCV) and other lethal diseases. Approximately 50 would contract HIV. In this context, an internal memo sent to a Becton Dickinson marketing director in 1990 could state that “treble costs [were] a tough sell” but “liability and injury cost escalations . . . [were] making it more possible.” For SFGH Bill Charney, the answer was more direct; the workers should be allowed to sue their employers for putting them at risk. “If hospitals were sued for millions of dollars every time a nurse got a needle stick, and the hospital didn’t supply safe needles,” he asserted, “you can bet this problem would have gone away years ago.”⁵⁵

In fact, under the Clinton administration, OSHA remained a reluctant partner in advocating for needlestick safety. Unwilling to challenge the health-care industry, or to confront companies like Becton Dickinson that refused to invest in developing new needle technology, OSHA ignored the impact of the corporate consolidation of health care. Three medical firms merged to form Premier, Inc., which then controlled one third of product purchases at hospitals in the United States, giving it enormous power to shape the market. Another industry group, Novation, required its 650 hospitals to purchase 95 percent of its needles from Becton Dickinson, which was the subject of a civil suit based on a defective needle. Still, the industry could point to the fact that treatment and burial costs of affected health-care workers were only $1 million; “the savings were,” as one industry speaker noted, simply “not there.”⁵⁶

Backed by the CDC and the American Hospital Association, SEIU had earlier petitioned the Food and Drug Administration to set new standards that would replace older, conventional needles with newer safer technologies. In its petition, SEIU argued that “the spread of HIV infection constitute[ed] a national public health emergency requiring urgent steps to curb its transmission.” Six years later, SEIU kicked off a campaign to push state legislatures to adopt engineering controls on sharps. Calling for “Safe Needles Now!” the union stressed the toll of inaction. More than 1 million health-care workers were injured, thousands contracted chronic terminal diseases from these injuries, and about 100 health-care workers died annually from diseases transmitted through unsafe needles. Moreover, as AFSCME president Gerald W. McEntee pointed out in May 1999, an estimated 40–50 new occupational HIV transmissions still occurred every year due to needlesticks.⁵⁷

Up to 75 percent of needlesticks, SEIU noted, could be eliminated by adopting the new technologies. California, where the state-level OSHA had prepared the way to mandate new needle technologies, was among the first to consider legislation to require safer needles. Supported by Kaiser Permanente, the state’s largest HMO, the SEIU’s Statewide Nurses Alliance was successful in passing a law in 1998 that went in effect in July 1999. Twenty other states — including Tennessee, Illinois, Maryland, Washington, Massachusetts, New Jersey, and Florida — were either considering or shortly thereafter passed similar bills.⁵⁸

In Washington, DC, after SEIU, AFSCME, and the American Federation of Teachers kept lobbying for needlestick safety legislation, OSHA at last joined the effort. It was time for a federal standard as the best means for reducing life-threatening injuries. Peter Stark (D-CA) and Marge Roukema (R-NJ) cosponsored the Health Care Worker Prevention Act, later renamed the Needlestick Prevention and Safety Act. As Stark argued, “Health care workers should not have to risk their lives while saving the lives of their patients. Safe needle devices are used in some facilities across the country, but our bill would make use of safe technology the norm rather than the exception.”⁵⁹ A consensus in favor of safety-engineered devices finally caught the attention of Congress.

By 2000, state laws and persistent pressures brought the issue to a congressional hearing and a bill for needlestick safety that had been introduced in 1999 to the floor. In hearings before the Workforce Protections subcommittee, RN Lorraine Thiebaud, an officer of SEIU local 790, charged, “In most hospitals across the country, needles without safety devices continue to be used. Little has changed, except that Peggy Ferro is no longer with us. . . . She died waiting for stronger federal action.”⁶⁰ As Karen Daley of the Massachusetts Nurses Association, SEIU health and safety officer Bill Borwegen, and Thiebaud testified, they had been committed to reducing the risks of injury and infection for more than a decade. It was time for a national standard to protect all health-care workers. The stories they told had a familiar ring. Like Peggy Ferro, who had testified in 1992, Karen Daley shared her experience after receiving a needlestick in a hospital emergency department where she had been a nurse for more than twenty years. Five months later, she “received the horrifying news that [she] was HIV and Hepatitis C positive.” She testified in the hearing, “It is impossible for me to describe to you how the one moment, the movement when I reached my gloved hand into a needle box to dispose of the needle with which I had drawn blood, has drastically changed my life.” She continued, “This injury didn’t occur because I wasn’t observing the necessary precautions, or because I was careless or distracted or not paying attention to what I was doing. Worst of all, this injury didn’t have to happen and would not have happened if a safer needle disposal system had been in place.” These devices had been commonly available over the previous two decades and could have sharply reduced “unnecessary” and “life-threatening” risks to health-care workers.⁶¹

Thiebaud provided similar evidence, illustrating her point with the stories of Peggy Ferro and Ellen Dayton. Dayton was a nurse who, protected in one workplace, had been exposed in another. She contracted HIV and HCV through a contaminated needle while working overtime at a clinic; but she was too sick to appear before the committee. Needlesticks, Thiebaud argued, were not “a small problem; they [were] an epidemic” and an unnecessary one at that, since safety needles existed. There was no reason for nurses, or indeed any health-care workers, to “suffer the same tragedy.”⁶² In testimony that followed, aptly called “Victims’ Stories” in the hearings, health-care workers described needlestick injuries and their responses, even when they did not contract a lethal disease. Kerry Aalbue, an emergency medical technician (EMT); LaShawn Johnson, a housekeeper; and nurses Karen Darden and Cecilia K (a pseudonym) noted how the conditions of work, and the lack of general guidelines to protect workers, had exposed them to unnecessary risks. Needles that had been carelessly laid on ambulance mattresses or over which workers lost control in the process of disposal exposed them to contaminated blood. Even the new sharps containers did not prevent such needle sticks. Health-care workers spoke as well of the “shock,” anxiety, and trauma related to the injury and the long wait to know whether one had contracted a potentially fatal disease.⁶³

Slowly, after the bill was introduced and hearings conducted in the House, the Needlestick Safety and Prevention Act gained momentum. Requiring health-care facilities to provide safer needles and blood-collection devices, to solicit health-care workers’ input into the selection of the new needles, and to maintain logs reporting on sharps injuries, the new federal law prescribed new safety regimens in hospitals and clinics, ambulances, and labs. Bolstered by growing public support, the legislation attracted 185 cosponsors in the House; it passed the Senate soon thereafter.⁶⁴ President Clinton signed the bill into law in November 2000. Local unions also made progress in pressuring individual employers to use safer devices. The San Francisco Chronicle and independent journalists had raised public awareness by investigating industry and by telling the stories of affected workers. The passage of the first law, in California, and campaigns for safer needles in other states had also played a role in moving the federal law forward. And yet, as Borwegen and Thiebaud noted, millions had been injured; thousands had become ill, and “too many ha[d] died” waiting for the government to act. Now, in passing this bill, it had.⁶⁵

Conclusion: The Impact of Further Cutbacks, Union Losses, and Intensification of Work

The 1992 OSHA blood-borne pathogen standard and the 2000 Needlestick Safety and Prevention Act made a difference in the lives of health-care workers. The OSHA standard had, first, promoted employee vaccination, which sharply reduced HBV; the Needlestick Safety and Prevention Act’s requirements for safety-engineered sharp devices had a similar impact on the hospital industry. By 2012, the New England Journal of Medicine reported that needlestick injuries declined by 38 percent among hospital employees. Examining nearly 24,000 injuries in 95 hospitals across 10 states, the researchers noted that injury rates remained low. Reviewing exposure control plans, maintaining injury logs, and creating a culture of workplace safety limited risk among health-care workers; so, too, did unions like SEIU Local 250, which put its bargaining clout behind the demand for safer sharps and initiated campaigns for state and federal laws.⁶⁶

Still, women health-care workers remain at particular risk, as women constitute nearly 80 percent of workers in the field. Nursing has become, as the SEIU and the National Nurses Union have argued, an even more dangerous profession, as the current coronavirus pandemic has revealed.⁶⁷ The shortage of personal protective equipment once again is a life-threatening problem that reveals the shortcomings of our health-care system. In fact, however, nurses are not alone; they are only third-ranked of health-care workers at risk of needlestick injuries and workplace violence and physical injuries. Patient aides, housekeeping, and food service workers, disproportionately minority women and men, have much higher injury and disease rates. Home health-care workers, including registered nurses and patient aides, are exposed to blood-borne pathogens, bodily fluids, and infectious agents in a far less regulated environment.⁶⁸

The intensification of labor in a world of corporate-managed health care continues to make the health-care industry more dangerous than it need be. Needlestick injuries remain a hazard to workers in most health-care occupations. What is more, the conditions that led to increased occupational risks for HIV and Hepatitis B, such as higher patient-nurse ratios, unregulated lifts and unsafe equipment, and isolated work assignments, endanger not just health-care professionals and service workers but also patients in their care.⁶⁹

In the past four decades, workers in the health-care industry have faced the consequences of industry deregulation, the underfunding of workplace oversight, and the general retreat of government from its role in protecting workers. Opposition to industry regulation, even as simple as safety needles and other devices were concerned, halted over and over again the effort to implement public policy on safety devices in health care. As Diane Feinberg, a nurse and LGBTQ activist argued in 1983, “AIDS [was] not just a medical crisis. . ., [it was] a profoundly political crisis as well.”⁷⁰ Extending that evaluation to the workplace, safety and prevention protocols became politicized in an age where the occurrence of HIV/AIDS may have been mitigated but the unions that advocated for health-care workers were and are more endangered.

The great unstated question is whether voters and taxpayers have understood what the conservative attack on the regulatory state has meant in individual and family terms. The increase in medical care mistakes, to take only one example, is a direct result of rising patient-caregiver ratios. By the 1990s, voluntary associations like unions and community organizations were the major advocates for continued regulation of the workplace and for new standards of workplace safety. Yet, the SEIU and the American Federation of Teachers, pioneers in demanding worker protection, recently closed their health and safety divisions.⁷¹ What remains to us, as we have seen in the passage of the Needlestick Safety and Protection Act, is vigorous and persistent action on behalf of safety legislation and for improved health-care and workplace safety. This brief has fallen to those sectors of the labor force that have an ethic of care — service providers, nurses, and teachers. Nurses have been pushing for an emergency rule that would require OSHA to ensure that hospitals are taking care of their employees during an unforeseen emergency, such as this pandemic.⁷² This rule had the support of labor unions and workplace safety activists. If enacted, it would mandate that “hospitals and nursing homes . . . create a plan to protect their employees from infections and to provide nurses and doctors with respirators” and allow OSHA “to apply the safety standard to others at high risk of contracting the virus, such as home health aides.”⁷³ Ultimately, only the actions of care workers themselves have kept the debate over occupational health protection alive and, with it, the promise of a safer working health-care environment for all.

The authors would like to thank the Graduate School and the Office of the Vice President for Research at Wayne State University for the research support that made our collaboration possible. We also thank Eileen Boris, Leon Fink, and anonymous reviewers of this journal.

References