An Ethnographic Account of Nurses in Kwazulu-Natal, South Africa
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The London School of Economics and Political Science Status, morality and the politics of transformation: an ethnographic account of nurses in KwaZulu-Natal, South Africa Elizabeth Alison Hull A thesis submitted to the Department of Anthropology for the degree of Doctor of Philosophy 2009 1 Declaration I declare that this thesis is the product of my own original research. Elizabeth Alison Hull 2 This work is dedicated to my parents, John and Marilyn 3 Abstract This thesis examines the ways in which a deeply entrenched nursing hierarchy is being reconfigured and challenged, and the status of nurses reshaped, in relation to wider political and social processes in the post-apartheid context. Specifically, it offers an ethnographic analysis of nurses working at Bethesda Hospital, a rural government hospital in northern KwaZulu-Natal. It argues that at this moment of liminal uncertainty characterising the current political and social transformation, nurses’ experiences are made meaningful both through a nostalgic reconstruction of the hospital’s missionary past, as well as through idioms that generate opportunities for – and a sense of control over – the future. These are all manifestations of a contemporary post-apartheid moment, yet they are also extensions of longer historical processes. This thesis, therefore, poses important questions about the nature of ‘transition’ in South Africa, and to what extent this has been marked both by rupture and continuity, in the localised context of a rural government hospital and its surrounding area. The thesis begins with an historical account of Bethesda hospital from its inception in 1937 as a Methodist mission hospital, and its eventual transfer to state control, describing a complex and changing micro-struggle for power in the context of a wider political economy of health care. It goes on to consider the influence of the hospital’s mission past on current practices, exploring the ways in which nostalgic memories feed into contemporary workplace debate. Such debate is framed by a context of severe and widespread ill-health exacerbated by the HIV/Aids epidemic, and the problems of staff shortage, fragmentation and poor pay and working conditions that provide ongoing and critical challenges to the institution and its employees. It considers how the moral concern provoked by this perceived crisis, and the preoccupation with hierarchy that has long been a feature of the South African nursing profession, are played out in relation to the emerging post-apartheid ideologies of ‘accountability’ and ‘rights’. Finally, it explores the ways in which nurses generate a mutual sense of purpose and control, while at the same time engaging in embattled struggles for status and self-recognition, through the practices of Born-again Christianity and international migration, showing how these offer new and powerful forms of status acquisition in the post-apartheid context. Based primarily on ethnographic fieldwork conducted at Bethesda hospital between December 2006 and October 2007, this thesis engages with theoretical discussions about social change and relationships of hierarchy within – and beyond – the workplace. Finally, it contributes to debates about the shifting fields of nursing and health care delivery in the wider South African context of immense political and social transformation. 4 Acknowledgements Many people have contributed generously to this project and have, in different ways, each helped to shape it. I am especially grateful to all the staff at Bethesda Hospital who gave up precious time to share their experiences and insights with me. Several people deserve particular mention. Musa Mathe and Plantina Mbowane both took special interest in my research and were always willing to talk, share ideas and help in whatever way they could. Philiphine Mathenjwa was the first nurse at Bethesda with whom I spoke: her depth of knowledge added richness to my data. The staff of the Human Resources Department were always forthcoming with my relentless inquiries, especially Nkosinathi Mthembu who was a great help and whose political and historical insight into the surrounding region filled many gaps in my knowledge. Kelly Gate assisted with much needed access to the wards, for which I am extremely grateful. Priscilla and Daryl Hackland and Steve Knight gave lengthy interviews at short notice and lent valued documents. Fortunate Mafuleka passed away before I finished this work, but I know she would have taken great interest in the final product, having helped so crucially during the first few months of my time at Bethesda and having been a companion throughout. I want to thank Dominique Oebell for generously giving up a room in the park home for a stranded researcher, and for the great times we spent living together. I owe a great debt of gratitude to Jabulile Gumede and Augusta Napier whose many hours of conversations fill up my fieldnotes and whose friendship and good humour prevented me from getting lonely. Outside of the hospital, I am deeply grateful to Thobile Myeni, Thabisile Dlamini, Ntombifuthi Nsele and Sibongile Ndwandwe whose warmth and kindness eased my transition into Ubombo, and to all the children of the Ubombo Children’s Care Village who provided a wonderful home on my arrival and who assisted greatly with my learning of Zulu. Dawn Irons kindly provided this accommodation. My research assistant Cynthia Gina was a close companion without whom my research in Nkangala would not have been possible. She is the source of a great deal of my knowledge of what goes on in the village. Solomon Myeni and Elphas Myeni facilitated and supported my research in Nkangala. Pieter Ryan gave up his time to assist me on several occasions, particularly when I needed an urgent lift to town and a mechanic. I am grateful to the nurses with whom I carried out research in the early stages at Guys & St. Thomas’ in London, and at McCord Hospital in Durban, who gave up their time for this project and whose insights gave clarity and depth to my later investigations at Bethesda as well as to the final outcome. In Durban, Eleanor Preston-Whyte introduced me to McCord Hospital and gave me a home for the first few weeks of my time there. Her warm hospitality and stimulating conversations stood me in great stead for the remainder of fieldwork. Janet Giddy and Steve Reid supported the project from the outset and were the crucial link to my discovery of Bethesda Hospital. For this, and for their enthusiasm and ideas, I am most grateful. I shared wonderful times in Durban with Fahad Hendrix, Pieter Nel, Masa Memela, Monty Thomas, Kate McCay and Rachel Arundel, who all provided a 5 welcome distraction from fieldwork. Their friendship was a refuge for me during my time in South Africa. The project was funded by the Economic and Social Research Council. I was affiliated to the History Department of the University of KwaZulu-Natal, to which I am grateful for arranging library access and for the weekly seminars which I often attended. The Department of Health of KwaZulu-Natal kindly granted the permission to carry out research at Bethesda Hospital. Members of staff at the Cory Library in Grahamstown provided access to the Methodist archives collection. My thanks are due especially to Zweli Vena whose impressive knowledge of the archives saved me untold hours. Various people have taken an interest in my research and have helped by reading my work, or by offering their expertise and advice in small or large ways. They include: Keith Breckenridge, Catherine Burns, Rabia Cassimjee, Deborah Gaitskell, Rick Iedema, Shula Marks, Julie Parle, Fiona Scorgie, Keith Shear and Helen Sweet. In the writing-up seminar at LSE, Catherine Allerton, Rita Astuti and Michael Scott each read a chapter in progress and provided insightful comments. It is difficult to imagine how this project could have come to fruition without the help and guidance of both of my supervisors. Deborah James has always kept sight of the big picture even when I struggled to see the wood for the trees. I am grateful for her immensely thought-provoking input and wealth of knowledge, and for her meticulous attention to my work. Matthew Engelke inspired my initial interest in the project and encouraged me to go ahead with it. Ever since, his questions have pushed me to think beyond my assumptions and have trained me to scrutinize my ideas. I’d like to thank all of my friends in London who have each helped me through at various stages, and especially Katya Nasim, Jonathan Price, Gordon Hodgson and Kate Aldridge for giving me a place to stay whenever I needed it. My friends and colleagues at LSE have read, discussed, and contributed ideas to many of the chapters of this thesis. We have shared each step of this journey together. They include: Irene Calis, Maxim Bolt, George St.Clair, Andrew Sanchez, Hans Steinmuller, Judith Bovensiepen, Katie Dow, Ankur Datta, Marina Sapritsky, Indira Arumugam and Hakem Rustom. Girish Daswani offered much needed advice in the early stages. Thanks to my siblings Imogen, Tom, Gab and Josh who have always supported me, and to nephew Solomon who has brought much joy to our family. My boyfriend, Fraser McNeill, has read and discussed vast swathes of this thesis at various stages which has helped to shape its outcome immensely. More so, his love and encouragement have been unfailing; a shelter from the storm. Finally, I would like to thank my Mother and Father to whom this thesis is dedicated, whose love, support and confidence in me are unending. 6 Contents Title page 1 Declaration 2 Abstract 4 Acknowledgements 5 List of maps and figures 9 Chapter 1. Introduction 13 Respectability and professionalization 16 Christianity and secularization 22 Health care in transition 25 Consolidating the language of ‘rights’ 30 Fieldwork and ethics 33 Situating Bethesda Hospital 39 Thesis scope and layout 43 Chapter 2.