No Support

Despite an alarming start, my father’s unexpected and sudden hospital stay was relatively uneventful: the nurses were kind, the food was mediocre and the clinical care was excellent. More disquieting was the pile of soiled laundry that sat on the floor of his room for three days. My mother, who had been a nurse, sniffed that in her day this would have been completely unacceptable.

And for good reason. As the chief public health officer of Canada recently reported, more than 200,000 patients acquire healthcare-associated infections every year; more than 8,000 Canadians annually die from them. More than half of -hospital-acquired infections are caused by antibiotic–resistant bacteria such as MRSA and VRE: for C. difficile alone, infection rates increased over 1,000 percent from 1995 to 2009. ((See “The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2013: Infectious Disease—The Never-Ending Threat.”)) Why, given the greater sophistication of medical treatments, as well the huge infusion of healthcare dollars over the past ten years, have conditions actually become so much worse?

In Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients, Dan Zuberi, a sociologist at the University of British Columbia, argues that one of the key factors explaining the rise of hospital-acquired infections has been the outsourcing of hospital support jobs in housekeeping and food service delivery. The author conducted 96 interviews at Vancouver area hospitals, which outsourced their support workers in 2003 and 2004. Prior to outsourcing, housekeepers made more than $18 an hour; after contracting out, this fell to less than $10. What this means, he argues, is that corners are cut so that contractors can remain competitive: workers are not trained properly or given adequate equipment, and sites are understaffed, contributing to ineffectual cleaning and staff burnout. “Stuff,” he notes succinctly, “gets missed.” In an intensive care ward, for example, a housekeeper is given 15 minutes to clean and disinfect a room thoroughly between patients: in hotels, staff are generally allotted twice this time to clean each room.

Zuberi presents a richly detailed account of the challenges faced by contractual support workers under this new economic regime. The causal relationship between outsourced labour and higher hospital infection rates, however, is always implied but never proven. Hospital-acquired infections are increasing across Canada, and not simply in sites with outsourced support staff. To the consternation of some readers, no doubt, and to the relief of others, there is no real statistical analysis in this book. It would have been useful to examine the relative rates of infection across a wide selection of hospitals using either in-house or outsourced support workers to see if a clear pattern of infection rates could be discerned, but the author does not do this. Nor does he attempt to quantify the extent to which outsourced labour (especially the quality of housekeeping) is responsible for higher infection rates compared to other factors. These include poor hand hygiene by visitors or healthcare professionals (10 percent of us unwittingly carry such bacteria with no symptoms); hospital design (too many shared rooms or bathrooms, or faulty ventilation); the use (or misuse) of antibiotics across the population; the large proportion of vulnerable individuals (often seniors) who are kept in infection-plagued hospitals rather than in sites with more appropriate forms of care, and so on.

Cleaning Up relies heavily upon the stories of the workers themselves rather than upon any theoretical analysis. But if this methodology is the main weakness of the book, it is also the source of its graphic evocative power. Statistics do not oblige us to consider what it is like to attend to a relentless tide of blood, vomit and urine given inadequate resources and even less respect. The surge of hospital-acquired infections may be an event of science fiction–like proportions, and one that we would be wise to address quite urgently; but in the end it is not really the subject of this book. Certainly it is not inconceivable that poorly trained, ill-paid and highly stressed workers are responsible for the frightening rise of MRSA and C. difficile; but the book’s real objective is to tell us who these people are, and to show us in palpable detail how broader policy decisions have affected the granular detail of their lives. Its approach is more Dickens than Darwin, and thoughtful readers might gain more by approaching the book as a novel rather than an academic treatise, for Dickens, no less than Darwin, was writing to enlighten his readers about the world that existed around them.

The widespread prevalence of serious infectious microorganisms is critically important, and we should perhaps view our hospitals more as Hieronymus Bosch–like realms of ubiquitous tiny terrors than zones of sterile efficiency; but the author is clearly more interested in people than in pathogens. What Zuberi does well is to sketch out the Dickensian landscape of the modern healthcare sector. The workers he profiles are expected to do more with less; workplace conditions are more harried, stressful and potentially hazardous than even before. Contract workers are now isolated from the healthcare teams, since they are answerable to their employers, located off-site, rather than to the hospital itself. Living conditions for Vancouver residents earning $20,000–$30,000 a year are painted in poignant detail. And Vancouver is not an isolated case: the epidemic of outsourcing has itself escalated dramatically, as it has become a useful mechanism for financially stressed health boards desperate to contain costs. Those hospitals across Canada that still use in-house support staff face relentless pressure to contract out these remaining services.

The larger context, however, is how hospital support workers fare in relation to the healthcare professionals with whom they work on a daily basis. Since 2000, when substantial federal expenditures began to flow into provincial healthcare systems, the gap between the average physician’s income and the average Canadian’s income began to diverge quite considerably. Ten years ago the average doctor made three and a half times the average Canadian’s salary; now that doctor earns four and a half times, even while providing fewer services than before. ((See Hugh Grant and Jeremiah Hurley’s “Unhealthy Pressure: How Physician Pay Demands Put the Squeeze on Provincial Health-Care Budgets,” University of Calgary School of Public Policy Research Papers, 6(22) 2013; see also Robert Evans and Kimberlyn McGrail’s “Richard III, Barer-Stoddart and the Daughter of Time,” Healthcare Policy 3(3) 2008.)) Part of the reason for this is political: Canadian physicians are well organized, and their professional associations are well funded and well run (in some cases, by key figures such as former provincial deputy health ministers). The historical settlement to the physicians’ strike in Saskatchewan following the implementation of public health insurance in 1947 meant that physicians were given a permanent seat at the policy table, with a say in determining many features of the provincial healthcare systems. Provincial governments, as Alberta learned recently, take on doctors in the court of public opinion at their peril.

We know that we live in an increasingly polarized world, and it is unsurprising that the healthcare sector should reflect precisely the same kind of growing disparity. We do not know, however, exactly what the consequences of this polarization will be for us as a society. Zuberi does not successfully prove his argument that outsourcing hospital workers causes greater rates of hospital-acquired infection. But the observation that the larger political decisions that dehumanize those struggling at the bottom affect us all, as Dickens suggested, still rings true.