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International Health Workers for People Over Profit
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Vol.2 No.2
March 30, 2010

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Assembly-Line Medicine

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By putting profits before people, capitalism damages human health, increasing the need for medical services. Escalating medical costs are compounded in nations with for-profit medical systems.

Unable to reduce the damage they do without cutting into profits and unwilling to pay more than necessary for medical care, the capitalist class has chosen to cut medical costs using the same methods they use in industry.

Modern factory methods were shaped in the 19th century by Frederick Winslow Taylor who developed a method to transfer control of the labor process to the capitalist class.

Taylor’s first principle is to de-skill the labor process. Managers gather all the traditional knowledge possessed by the workers and reduce it to simple rules and formulas. Time-and-
motion studies are one way to do this. Management can then re-design the work for maximum productivity.

Taylor’s second principle is to separate thought from action. All possible brain work is removed from the shop floor to the planning department. Those who make all the decisions do none of the actual work. Those who do all of the work make none of the decisions; they are reduced to “hands.”

Taylor’s third principle is for management to control every step of the labor process. Each worker is given detailed instructions describing the tasks to be accomplished, the method to be used and the time allotted. The worker is reduced to an animated tool of management, a general purpose machine, adaptable to a large range of simple tasks.

Because they proved so effective for cutting costs and subordinating the work force, Taylor’s methods spread to other sectors of the economy, including food service, education and medicine.

Hospital Factories

Modern hospitals function like factories, where different departments attend to different parts of the body in assembly-line fashion, moving patients through the system within predetermined time limits.

In 1985, a team of specialists at Harvard University developed the Resources-Based Relative Value Schedule (RBRVS), which applies industrial time-and-motion studies to the practice of medicine. The RBRVS ranks and rates physician services according to the time, mental effort, physical effort and stress required to perform those services.

The RBRVS has become the primary method for determining physician payments. However, it can be used for much more than that. Dissecting medical work into its component parts and pricing those parts makes it possible to apply the same de-skilling, dehumanizing methods that are so profitable in industry.

Under “managed care,” physicians who were trained to use skill and judgement to diagnose and treat patients are provided with detailed manuals listing the services to provide for each condition they encounter. Management can also hire cheaper workers to perform the less-skilled portions of medical tasks. Wherever possible, physicians are being replaced with nurse practitioners; registered nurses with practical nurses; practical nurses with orderlies; orderlies with clerks, and so on.

The Impact on Health Workers

Today’s medical institutions are dominated by managers obsessed with budgets, “cost-efficiency” and “cost-containment.” In contrast, the priority for health workers is providing patient care. The result is class conflict, as workers battle managers bent on making them do more for less at the expense of their health and the health of their patients. In the following comments, nurses in the United States, Canada and Northern Ireland describe their experiences.

Eileen Prendiville works as a registered nurse in a San Francisco hospital:

With managed care, registered nurses were laid off by the thousands and replaced by unlicensed personnel and licensed practical nurses with less training. The registered nurses who remained were overworked and overstressed, and they left the profession in droves, creating an industry-wide shortage of RNs.

The California Nurses Association fought for passage of the first Nurse-to-Patient-Ratio law in California to prevent more nurses from being laid off and to protect patients. Studies showed that patients in hospitals with more RNs had fewer hospital-acquired infections and better overall outcomes.

Despite legal challenges by the hospital industry to prevent enactment of the law, it passed, and many registered nurses returned to acute care. To keep costs down, hospitals cut ancillary staff such as unit clerks and practical nurses, making RNs do more non-nursing tasks.

As the economic downturn progressed from late 2008 to 2009 and the newly-unemployed lost their health insurance, my hospital froze our wages and imposed a hiring freeze. Each department was required to cut its budget by at least 10 percent.

Our full-time functional attendant who stocked our unit, ordered supplies and kept track of special equipment was laid off. Nurses, unit clerks and central service staff are now expected to pick up her duties. Lactation consultants were let go, and medical translators were laid off but asked to stay on a per-diem basis (without benefits). Vacated nursing positions were left unfilled for months, while the patient load remained high.

There are reports of managers in non-union units refusing to pay for missed meals and missed breaks and illegally altering time-cards to avoid paying overtime.All this to stay within their budgets.

Non-union employees are afraid to speak up for fear of losing their jobs. Unionized nurses who uphold the mandated standard of patient care are constantly harassed and disciplined for ridiculous and petty things.

RNs and other health workers have organized unions and umbrella organizations, like National Nurses United, to step up the fight for patient care. Members of the California Nurses Association have also joined the San Francisco Labor Council to advance our common interests.

Aisha Jahangir works as a registered nurse in an Ontario hospital:

I’ve been nursing for about 12 years now. When I first started, I was given the opportunity to care for the WHOLE patient. Nurse-patient ratios were a lot lower then. Nurses didn’t have as many patients to care for, so the nurse could devote more time and thought to her care. I had time to give my patients a nice back rub and other evening care. How have times changed!

Now, the only reference to evening care is about giving medications. Forget about back rubs. You won’t even find lotions to give one, let alone have the time. My day is spent delivering meds and making sure patients are discharged before 11am, so housekeeping can turn the rooms around quickly enough to fill them with new admissions.

I am expected to please the manager and save the hospital money more than I am expected to make sure that my patients get quality care. I often stay late to document what I have done, because there is no time allotted in my shift for that. I wish that I could bring back all that we have lost.

When I first started, the maternity ward was divided into labor and delivery, postpartum, and the nursery. On the postpartum unit, you would normally have four sets of moms and babes to care for and a maximum of five or six. This gave nurses time to teach newborn care and provide breast-feeding support. All in all, the nurses felt that the work was manageable, and both patients and nurses were satisfied.

Then the hospital decided to turn the maternity ward into a labour-delivery-recovery-postpartum (LDRP) unit where each laboring nurse would be with one patient from admission to discharge. A lot of money was spent to cross-train the staff to work in all areas of labor and delivery, postpartum and the special-care nursery. It sounded good, but it didn’t work out.

Not enough rooms were built to accommodate all the moms, so we had to move patients through the system more quickly. There was resistance from staff who were expected to be skilled in all three areas, and we were often short on laboring nurses. This meant that once a laboring nurse had delivered her patient, she had to move quickly to the next laboring mom and never saw her patients through the whole process.

Our manager has cut back on supplies to save money, and we no longer provide much to patients. Patients are instructed to bring a lot of things with them from home (especially pillows) because we often don’t even have one pillow per room. We provide only a few diapers, and it is getting tighter and tighter. Just recently the manager stopped ordering drinking straws. The manager often stalls on replacing sick nurses, leaving us short. The end result is overworked, stressed-out nurses and patients not getting the care they deserve.

Patricia Campbell works as a registered community psychiatric nurse in Belfast, Northern Ireland:

Our National Health Service has changed significantly since its inception. Privatisation took hold during the Thatcher years, and Labour continued Thatcher’s policies, dismantling a health service that was once the envy of the world. While all NHS patients have health care in principle, the waiting lists for essential procedures and life-saving operations are increasing. As a result, many people are forced to go private.

In Northern Ireland, mental health services are grossly underfunded. Young people requiring specialist treatment for eating disorders and personality disorders must go to England for treatment. They are effectively exiled from their own country, far away from their families and friends. So health care is not really available for all.

As the cuts bite deeper, frontline health workers are expected to do more for less. Well-paid bureaucrats have started at the bottom of the pay-scale, attacking the most vulnerable, lowest-paid workers first.

Administrative staff have already lost their jobs, and nurses and social workers are now expected to record meetings, answer phones, file notes, type, order supplies and deal with enquiries from the public. These duties are added on to our already extremely busy work schedule.

Meanwhile, flash-frozen meals that are prepared offsite (like the meals served on aeroplanes) are replacing freshly-cooked meals that were previously prepared for patients in the kitchens. Not only are patients losing out in terms of nutrition, cook-staff are being downgraded to food servers. Cooking skills are no longer required. The work force is being reduced, and essential skills that benefit patients are being lost to benefit private companies.

We don’t have a strong union leadership here in Northern Ireland, and this is reflected in the way our health service is being run down. We are building a new union for health workers, because the existing unions are more interested in developing a relationship with management than in protecting the rights of patients and health workers.

Expanding the Class Struggle

Hospitals that are run like factories are unsafe for workers and patients. Every year, an estimated 98,000 Americans die from preventable medical errors and another 99,000 patients die from hospital-acquired infections, most of which are also preventable. In total, the death toll from preventable medical injuries and infections in the US is close to 200,000 people per year, more than motor vehicle accidents, poisoning, firearms and falls combined.

The key to prevention is high staff-to-patient ratios, so that health workers have enough time to tend to patients, to ensure that everything is done correctly, and to provide sanitary facilities and nutritious food.

Staff-to-patient ratios promote quality care. But capitalism is not about quality care. Its priority is to make profit and control the subsequent damage in the cheapest way possible. The hospital industry opposes staff-to-patient ratios because they interfere with the ability of managers to cut costs and, in the private sector, to raise profits.

By expanding Taylorism to the service sector, capitalism has expanded the class struggle. Modern class conflict, born in the factories of the industrial revolution, has now spread to every fast-food outlet, school and hospital. Opportunities have never been better to build a unified movement of the working-class that can put human neeed ahead of corporate greed.

This report was compiled by Susan Rosenthal, a Toronto-area physician and the editor of PEOPLE FIRST!

Crisis Económica y Salud Mental

    por Sergi Raventós - Catalunya (Reino España)

Uno de los efectos de la crisis económica no muy publicitado es el de las graves repercusiones que tendrá en la salud de las personas y más concretamente en la salud mental.
Antes de la crisis económica

El periódico de  La Vanguardiadel 16/09/07 alertaba que uno de cada cuatro europeos (28% mujeres, 21% hombres) padecerá de algún trastorno mental en su vida. Fundamentalmente depresión y ansiedad.  El mismo diario casi 2 años después, el 14  de Abril del 2009 publicaba que el 30% de las consultas al CAP son por motivos de salud mental: un 10% de depresión, un 7% de ansiedad, el 6,6% de fobias, el 3,5% crisis de pánico i el 3,2% de abusos de substancias.

La crisis intensificará y agravará una epidemia de depresiones que anunciaba la Unión Europea (UE) antes de la crisis. Concretamente el año 2005 la UE elaboraba un documento llamado Libro Verde. Mejorar la salud mental de la población. Hacia una estrategia de la Unión Europea en materia de salud mental (1). El documento afirma que el 27% de los europeos adultos padecen alguna forma de alteración psíquica a lo largo de su vida. En la UE, las formas más comunes de enfermedad mental son la ansiedad y la depresión. Se espera que la depresión sea la primera o segunda causa de enfermedad durante el año 2020 en el mundo desarrollado.

Los datos de la crisis

Así pues, si antes de la crisis ya se manejaban estas cifras, después de la misma que por lo que dicen los expertos ya es una de las más graves de los últimos años, cuesta hacerse una idea ajustada de como será la salud mental de la población en los próximos años.  Un ejemplo puede ser indicativo: Un artículo de la Vanguardia del 9 de marzo del pasado 2009 apuntaba que “Bretaña se prepara para una ola de depresiones. Tres millones de parados, jubilaciones anticipadas, decenas de miles de viviendas expropiadas, empresas que cierran cada semana, bancos que se niegan a conceder crédito mientras que sus ejecutivos se embolsan bonos multimillonarios, las acciones por los suelos, los fondos de pensiones evaporados, el futuro del capitalismo en entredicho...Y puede sorprenderle a alguien que se avecine una ola de depresiones?”.  

Según algunos expertos como Barry s. Levy i Victor W. Sidel en un artículo de la revista Medicina social (2) consideran que la actual crisis económica mundial comportará algunos de los retos más grandes que se hayan presentado nunca para la salud pública. Enumeran diez:

1. desnutrición y consumo de alimentos menos nutritivos
2. incremento de la población sin hogar
3. el paro y lo que comporta: pobreza relativa, perdida de autoestima, comportamientos poco saludables, aumento de suicidios, etc.
4. Drogadicción, depresión y otros problemas de salud mental (más tasas de alcoholismo, suicidios...)
5. mortalidad aumentada
6. salud infantil deteriorada
7. violencia (producto de la frustración, desesperación de estar en paro, subocupación...)
8. problemas de salud ambiental y laboral
9. injusticia social y violación de derechos humanos
10. problemas de disponibilidad, accesibilidad de los servicios de atención médica, etc.

Como observan estos autores muchos problemas de salud mental graves vendrán derivados de algunas de las consecuencias de la crisis como el paro, la violencia o la falta de vivienda. A estas alturas esto le extraña aún a alguien?


Es un breve documento pero con un diagnostico de la situación preocupante. Se puede consultar en: (2) Ver el interesante pero preocupante artículo de Levy Barry S. , Sidel W. Victor (2009): “Crisis económica y salud pública”. Medicina Social, vol 4, núm. 2.

Sergi Raventós - Trabaja en una Fundación sociosanitaria de salud mental y realiza el doctorando de Sociología por la UAB. Es miembro de la plataforma en defensa de la salud pública Dempeus y de IHWPOP (International Health Workers for People Over Profit).


International Health Workers for People Over Profit (IHWPOP) has joined the Boycott, Divestment and Sanctions Campaign against Israel. We oppose Israel’s repression of the Palestinians and support a single state in Israel/Palestine with equal rights for all.


All of the material in this newsletter is made available to the public under the terms of the Creative Commons Code. Readers are welcome to share and use this material for non-commercial purposes, as long as they acknowledge the author(s) and International Health Workers for People Over Profit



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