Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients 9780801469824

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CLEANING UP

A volume in the series The Culture and Politics of Health Care Work edited by Suzanne Gordon and Sioban Nelson A list of titles in this series is available at www.cornellpress.cornell.edu.

CLEANING UP How Hospital Outsourcing Is Hurting Workers and Endangering Patients Dan Zuberi

ILR PRESS AN IMPRINT OF CORNELL UNIVERSITY PRESS ITHACA AND LONDON

Copyright © 2013 by Cornell University All rights reserved. Except for brief quotations in a review, this book, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850. First published 2013 by Cornell University Press First printing, Cornell Paperbacks, 2013 Printed in the United States of America Library of Congress Cataloging-in-Publication Data Zuberi, Dan, author. Cleaning up : how hospital outsourcing is hurting workers and endangering patients / Dan Zuberi. pages cm. — (The culture and politics of health care work) Includes bibliographical references and index. ISBN 978-0-8014-5072-3 (cloth : alk. paper) ISBN 978-0-8014-7896-3 (pbk. : alk. paper) 1. Hospital housekeeping—British Columbia—Vancouver. 2. Hospital care— Contracting out—British Columbia—Vancouver. 3. Hospital care—British Columbia—Vancouver—Safety measures. 4. Hospitals—British Columbia— Vancouver—Employees. 5. Nosocomial infections—British Columbia—Vancouver. I. Title. RA975.5.H6Z83 2013 362.11068'4—dc23 2013013924 Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. For further information, visit our website at www.cornellpress.cornell.edu. Cloth printing Paperback printing

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To the memory of Helen Robinson, who loved a good book.

Contents

Acknowledgments 1.

“Stuff Gets Missed”: An Introduction to a Growing Health Care Crisis

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1

Germs, Blood, and Cost-Cutting: The Daily Struggle to Keep Hospitals Clean

19

Compromising Cleanliness: How Outsourcing Keeps Hospital Workers from Doing Their Jobs

36

4.

Untrained Workers, Unfit Managers

51

5.

Breaking Up the Team

67

6.

Down and Out in Vancouver: Struggling, Stressed, and Exhausted Hospital Support Workers

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2.

3.

7.

Cleaning Up

Notes References Index

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127 149 175

Acknowledgments

I thank the many people who helped me complete the research behind this book and its publication. First and foremost, the interview participants, who remain anonymous, made this work possible by sharing their time, stories, and invaluable insights. While their stories, at times, broke my heart, I applaud their hard work, dedication, and commitment. I also extend an extraordinary thank you to Melita Ptashnick, who began working on this project before returning to school to complete her MA degree and has worked for years helping collect, analyze, and disseminate data as a research assistant and coordinator on this and several other ongoing research projects. I have been fortunate to have the help of many research assistants for this study, including Tamara J. Ibrahim, Michael Halpin, Katherine McCallum, Geraldina Polanco, and Ariel Taylor. I am especially appreciative of the Social Sciences and Humanities and Research Council of Canada for a Standard Research Grant, which supported this research. This research also benefited from a UBC Dean of Arts Undergraduate Research Award and a New Investigator Salary Award from the Canadian Institutes of Health Research (2011–2016). This research would not have been possible had it not been for the help and support of several staff members at the Hospital Employees’ Union, especially Marcy Cohen, Chris Kincaid, Deborah Littman, and Jennifer Whiteside. Throughout my career, I have been fortunate to benefit from the mentoring of many senior scholars who are leaders in their field. I thank my undergraduate honors advisor, Patricia Fernandez-Kelly and my MSc advisor at Oxford, George Smith. I am especially grateful for the ongoing support and mentorship of my PhD supervisor, Katherine S. Newman, dean of Arts and Sciences at Johns Hopkins University, and my supervisory committee members William J. Wilson and Mary C. Waters at Harvard University, as well as Jeffrey Reitz at the University of Toronto. I also thank my post-doctoral supervisor at the University of British Columbia (UBC), Clyde Hertzman, and my early career mentors: Neil Guppy at UBC and David Hulchanksi and Sheila Neysmith at the University of Toronto. I thank Faye Mishna, dean of the Factor-Inwentash Faculty of Social Work and Mark Stabile, director of the School of Public Policy & Governance at the University of Toronto for their support.

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ACKNOWLEDGMENTS

I have been fortunate to have had the support and encouragement of many people during this research project. I enjoyed the opportunity to spend part of a sabbatical at the Department of Sociology at the University of California, Berkeley, with the sponsorship of Peter Evans, who I thank for his encouragement. I also thank Irene Bloemraad and Kim Voss for their support. I was especially fortunate to return to Harvard as the William Lyon Mackenzie King Research Fellow at the Weatherhead Center for International Affairs in 2011–2012 while revising the book manuscript. I am grateful to Canada program staff, including Steven B. Bloomfield, executive director; Helen Clayton, program coordinator; and Thomas C. Murphy, for their help. It was wonderful getting to know and work with Jim Dunn. I also thank Mary Jo Bane, Lisa Berkman, Kathryn Edin, Marshall Ganz, Peter Hall, Christopher Jencks, Michéle Lamont, Pamela Metz, Jim Quane, Beverly Silver, and Eddie Walker. Over the course of this project, I have enjoyed the support and encouragement of many colleagues whom I thank, including Peter Adler, Joan Anderson, Rosemary Batt, Shyon Baumann, Sarah Brayne, Alex Colvin, Jennifer Chun, Adrienne Davidson, Julian Dierkes, Gary Evans, Richard Freeman, Ann Frost, Dan Hiebert, Nancy Gallini, Rebecca Givens, Anna Haley-Locke, Charles Hirschmann, Crawford Kilian, Seth Klein, Sarosh Kuruvilla, Robert Kuttner, Susan J. Lambert, Sean Lauer, Judith Lynam, Ruth Milkman, Peter Moskos, Dianne Newell, Aimee Nygaard, Winnie Poster, Patrick Sharkey, David Tindall, Chris Tilly, Lowell Turner, Danielle van Jaarsveld, Paul Watt, Rima Wilkes, Elvin Wyly, and Carrie Yodanis. At Cornell University Press, it is always a pleasure to work with Fran Benson, who believed in and was enthusiastic about this research from its beginning. I have been inspired by the amazing work of Suzanne Gordon, author and co-editor of The Culture and Politics of Health Care Work series, and learned a great deal from her advice. I also appreciated the feedback from Siobhan Nelson, co-editor of the series, on the manuscript as well as the feedback from the anonymous reviewers. I appreciate the help of senior production editor Karen Laun, copy supervisor Susan Barnett, marketing director Mahinder Kingra, and copyeditor Julie Nemer. I thank Diana Hembree, health journalist, for her help and advice. I had the extremely good fortune to work with brilliant editor, Chris Woolston. I also appreciate the dedicated transcription work by Tara Neufeld. I thank faculty at the following institutions for the opportunity to present the findings of this research: Harvard University; University of Washington, Seattle; Cornell University/ILR School; American University; Portland State University; San Diego State University; University of British Columbia; and University of Toronto.

ACKNOWLEDGMENTS

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Parts of chapters 1 and 6 appeared originally in the American Behavioral Scientist 55(7) (2011): 920–40. Those passages are reproduced here with permission from Sage Publications, Ltd., from Daniyal Zuberi, Contracting Out Hospital Support Jobs: The Effects of Poverty Wages, Excessive Workload and Job Insecurity on Work and Family Life, © Sage Publication, 2011. The past several years have been full of adventures and travel from Vancouver to San Francisco, to Boston, and now to Toronto. I thank my friends, who have opened their homes to us over the years and whose company I’ve enjoyed over many dinners and outings: Alan Jacobs and Antje Ellermann, Tamara Smyth and Tommy Babbin, Shannon Daub and Ryan Blogg, Wendy Roth and Ian Tietjen, Anand Das and Shilpa Patel, Catherine Bischoff and Tom Zehetmeier, Kyle Horner and Kyla Tienhaara, Amy Hanser and Nathan Lauster, Mark Koehler and Linh, Jeremy Weinstein and Rachel Gibson, Joiwind and Amit Ronen, David and Sarah Pinto-Duschinsky, Molly and Ty Sterkel, Sam Jones and Pierre Koch, Veronique Sardi and John Parinello, Trish Winston, Jen Darrah-Okike and Kanu Okike, Judith and Hanno Steen, and Arjumand Siddiqi. I have also been blessed to have the support of my wonderful family. My two daughters, Saskia and Naomi, bring unimaginable joy into my life. My spouse, Joanna, what can I say? I can’t thank her enough for her support and love, for believing in me and this book through it all, for reading and re-reading chapter revisions, and for reminding me why these stories are important to share and understanding why it’s just wrong that so many needlessly suffer. Keeping me grounded, giving me perspective, reminding me of what’s important, for being there. As anyone who has met her knows, she is simply amazing. I thank my mom, Lilly Zuberi, for being such a wonderful person and my father, Mo Zuberi for his support. I also thank my sisters Anita Zuberi (and her husband Steve Chase) and Sofia Zuberi (and her fiancé Jakob). I also am especially grateful to my father-in-law, Cam Robinson, who keeps me updated with the latest Scientific American articles on antibiotic resistance and has been so supportive and kind. My sister-in-law Michelle Robinson and family, Charles Lepoutre, Georges, and Élise have been the best hosts so many times. I thank Leslie Robinson, Kate and Graham, Toni and David Owen, and Jennifer Owen. My family has been greatly saddened by the passing of Helen Robinson and Jean Vivian. With the passing of loved ones and births of new family members, we celebrate the joy and beauty of life so intricately and intimately connected to struggle and loss, remember how we can honor those before us, and work toward a more just, safer, and more sustainable future for the generations to come.

CLEANING UP

1 “STUFF GETS MISSED” An Introduction to a Growing Health Care Crisis

Tracy Melucci cleans a hospital for a living.1 Well, sometimes clean is a strong word. More realistically, she makes her hospital less dirty than it was before. Short on time, short on resources, and long on responsibilities, she cleans what she can. And she knows it’s not enough. “Basically, you do the big stuff and then you start cutting corners,” she says. “You just cannot get it all done. And when I say ‘cutting corners’ that means bathrooms, offices, hallways. Stuff gets missed.” Stuff gets missed. Hospitals across the United States, Canada, and much of Europe have dramatically changed their approach to housekeeping and other support work in the last decade, and people are dying as a result. Disinvestment and outsourcing of hospital cleaning services have left hospitals less hygienic and more vulnerable to the spread of hospital-acquired infections. A Philadelphia grandmother checked into a hospital for a minor knee operation. The operation should have greatly improved her mobility and quality of life; instead, it opened the door to an infection of methicillin-resistant Staphylococcus aureus, or MRSA. The infection—which most likely could have been prevented—burrowed into her joint and started devouring all the tissue it could reach. Doctors removed her knee and amputated her leg. But even after a total of twenty surgeries, the germ still prevailed. In spring 2010, she died from the infection at the age of seventy-seven.2 Drug-resistant germs let loose in less-than-spotless hospitals—it’s a scenario for disaster. According to the World Health Organization (WHO), hundreds of millions of patients get infected annually.3 Millions die as a result, and many others will be struggling to recover, often spending several extra days, weeks, or 1

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months in a hospital bed. The U.S. Centers for Disease Control reported a decline in MRSA cases in the United States from 2005 through 2010,4 but, C. difficile infections remain at “historic high levels.”5 Overall, the problem of hospital-acquired infections shows no signs of slowing down. In fact, many infection-control professionals and researchers fear it is going to get a whole lot worse. That is the reality of today’s health care system: The very places patients go for treatment and healing can, instead, be a source of severe illness and even death. According to WHO, at least 1.4 million people are suffering from a health care– associated infection at any one time.6 This is not a problem confined to developing countries; many of the most serious cases are in the United States, Canada, and Europe.7 Despite differences in monitoring, measurement, and reporting across regions and countries, it remains clear that health care–associated infections are a leading cause of illness and death. According the U.S. Centers for Disease Control, 1.9 million people every year are infected in U.S. hospitals and 99,000 people die.8 Many of the survivors suffer long-term health consequences and even disability. The statistics are similarly dismal for Canada. Linda Raines, an infection-control nurse at a Vancouver hospital explains, “hospital-acquired infections are the third or fourth leading cause of death in Canada. That is staggering to me. Over 220,000 Canadians are affected by hospital-acquired infection every year, and out of that approximately 8,000–12,000 actually pass away due to it.”9 Hospital infections are also incredibly expensive to treat. In the United States, one economic estimate put the cost at $6.7 billion per year.10 In Canada, direct treatment costs are estimated at approximately $1 billion per year.11 These costs do not include financial settlements or damages awarded from the growing number of lawsuits and compensation claims filed by victims and their families as a result of health care–associated infections.12 These estimates also do not take into account the loss of economic productivity or the pain and suffering of victims. The prevalence of health care–associated infection literally means that people risk their lives whenever they enter a health care setting or hospital to get treatment. How high is this risk? A 2009 article published in the Canadian Medical Association Journal estimates that one in ten adult hospital patients contract an infection before being discharged, which is similar to estimates from other countries, ranging from the United Kingdom to New Zealand.13 In the United States, roughly 70 percent of hospital-acquired infections are resistant to one or more antibiotics.14 It’s frighteningly easy to pick up an infection during a hospital stay. Linda Raines, infection-control nurse, relates this story: “We had a patient that was a cath lab nurse in a different hospital, and obviously as a nurse she was very aware of her surroundings and her hand hygiene. She was in the hospital three times and by the third admission she was MRSA positive. To me, she was the top of the top as far as doing everything right, and it just took three visits.”

“STUFF GETS MISSED”

3

Catherine Noonan, another nurse and infection-control practitioner in Vancouver, explains, “I don’t think that the average person knows enough about the organisms that they come with, the organisms that they encounter in the hospital, and how transmission occurs.” Veronica Sendal, an epidemiologist who consults on infection-control reform to U.S. hospitals, says that the general public has somehow managed to live in denial about the risk of hospital-acquired infections, even though most everyone knows someone who has been affected. And, she says, it’s not just the public that underestimates the risks: “Health care workers have some knowledge of the frequency and severity of HAIs [hospital-acquired infections] but do not always realize the impact of their own actions nor do they necessarily prioritize prevention in day-to-day activities. We do not have a total understanding of the host, agent, and environmental factors that contribute to the incidence of infection nor do we know or have the technology, means, or commitment to safely prevent HAIs.” Getting infected in the hospital dramatically increases the likelihood that a patient will require extensive care or even die. The most dangerous cases of hospital-acquired infections result in pneumonia or infection of the bloodstream, gastrointestinal system, surgical sites, skin, or soft tissue.15 Getting an infection complicates care and requires extended treatment and even hospitalization. A report from the UK Health Protection Agency estimates that a patient with a health care–associated infection is 7.1 times more likely to die than a similar uninfected patient.16 It’s not a pleasant way to go. People with an infection of Clostridium diff icile— a superbug that’s on the rise in hospitals across the world—have likened it to “swallowing shards of glass.” Patients may suffer from unstoppable diarrhea for weeks before finally dying.17 Even if they survive and recover, they can suffer lasting health consequences. Louisa Appleton, an infection-control practitioner in Vancouver laments, “people don’t realize that their legs could be amputated or they can die from it or they end up losing their bowels when they get C. diff.” The problem is rapidly becoming even more serious.18 Overall, all kinds of infections are becoming more widespread, more difficult to treat, and more dangerous to patient health. According to the U.S. Centers for Disease Control (CDC), health care–associated infections are a top-ten cause of death of Americans.19 While this overall assessment may seem pretty grim, the on-the-ground reality is actually worse than the numbers suggest. Many infections and casualties of health care–associated infections are misattributed or simply not reported. Whether they want to or not, hospitals are fighting a war against germs. Professor Arthur Sanders, a senior faculty member and leading expert on infectious disease, certainly feels like the germs are winning: “I talk about hospitals

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as cesspools. Hospitals are an important vehicle for bad infections and resistant infections to go into the community, and then ultimately back to the hospital setting. So, pretty well in every way I can think of, they’re a significant issue, and perhaps what makes it more frustrating is that many of these are, in theory, preventable if healthcare providers and administrators did their jobs.” The situation is scary, but it is far from hopeless. In fact, hospitals in Scandinavia and the Netherlands have managed to greatly reduce the prevalence of hospital-acquired infections with a series of policy reforms—the types of reforms that could be implemented elsewhere but aren’t. The steps include incentives to increase hand-washing, prevent the overuse of antibiotics, increase careful monitoring, and, crucially, increase the training and professionalization of hospital cleaners and support workers.20 Julia Drake, a medical lab microbiologist working in a British Columbia public health lab, explains, “I think there are European cities that are very advanced in terms of infection control. I’ve been through hospitals in Germany where they actually sterilize the entire patient bed. That may be overkill but they basically sterilize every bed, and put it in plastic wrap, so you have a brand new bed that’s totally cleaned up, ready for the next patient. Well whether that’s necessary is debatable, but there’s full spectrum of the pendulum. . . . there are countries that pull out all their stops.” Globally, hospitals and health care systems have adopted a variety of approaches to prevent superbug outbreaks and reduce infection rates. The WHO, for example, is attempting to encourage hand-washing and other infection-control guidelines around the theme of “Clean Care Is Safer Care.”21 The good news is that many of these interventions have resulted in proven reductions in infection rates. They are all well worth the cost and investment required to implement, especially in light of the emergence of new deadly strains of antibiotic-resistant bacteria, such as C. difficile, vancomycin-resistant Enterococcus (VRE) and vancomycinintermediate/resistant Staphylococcus (VISA/VRSA).22 Yet the calls for increasing hand-washing and implementing safe-care checklists should be viewed only as a good start. Because of the urgency of the threat from hospital-acquired infections, the crisis must be attacked simultaneously from multiple fronts.23 The good news is that multipronged approaches have been proven effective for quelling an outbreak or reducing overall infection rates. Here are some recent success stories: • The University of Pittsburgh hospital reduced C. difficile infection rates by 50 percent through improved cleaning, antibiotic stewardship, and isolating infected patients.24 • St. Michael’s Hospital in Toronto reduced MRSA infections by 60 percent through improved cleaning by 2006, and according to publically available

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hospital surveillance reports, reported fewer than ten new MRSA cases in 2011.25 • In 2008, the United Kingdom completed a deep clean of 1,500 hospitals at a cost of £63 million. The UK National Audit office estimates that spending £120 million on cleaning (including the deep clean) saved between £143 million and £263 million in treatment expenses.26 • An 2011 article in the New England Journal of Medicine describes how a multipronged approach, including surveillance, contact precautions, hand hygiene, and institutional cultural change to involve all staff in infection control, successfully reduced hospital-acquired infection rates at U.S. veterans’ hospitals.27 The research evidence clearly points to the importance of environmental hygiene—or hospital cleanliness—for preventing the transmission of hospitalacquired infections. In a 2008 article in Lancet Infectious Diseases, Stephanie Dancer, microbiologist, notes that “cleaning has already been accepted as an important factor in the control of . . . hardy environmental pathogens such as Clostridium difficile, vancomycin-resistant enterococci, norovirus, and Acinetobacter spp.”28 Her article presents detailed evidence that hospital cleanliness is also a key factor for controlling transmission of MRSA. In another article published in BMC Medicine, Dancer and her colleagues reported the findings of a controlled experiment that found adding one extra cleaner to a ward resulted in a decline in measured microbial contamination detected on hand-touch sites, prevented many infections, and generated substantial savings.29 Other research clearly shows that proper and thorough cleaning of high-touch surfaces and other germ hot spots in hospitals can reduce the rates of hospitalacquired infections. In their review of the literature, Philip C. Carling, director of epidemiology at Boston’s Carney Hospital, and Judene M. Bartley note that “five studies have recently shown that improved routine disinfection cleaning practice is associated with an average 40% decrease in transmission of VRE, MRSA, and A. baumannii.”30 Unlike typical housekeepers, hospital cleaners are supposed to completely disinfect all surfaces of the room to make it safe for the next patient. But they rarely meet this goal. Currently, patients who stay in a room where the previous occupant had an infection such as MRSA, C. difficile, VRE, and Acinetobacter baumannii have been found to have a 73 percent elevated risk of getting infected compared to other patients.31 It may seem obvious that the people who mop the floors and wipe off countertops—the people on the front lines of hospital hygiene—could play a

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key role in preventing the spread of hospital-acquired infections. But in most of the world, these workers are practically afterthoughts, if anyone bothers to think about them at all. Previous research on hospital support workers in the United States and Canada reveals that they feel devalued and ignored, despite the importance of the work they do.32 My research identifies the largely overlooked connection between deteriorating working conditions in hospitals and the increase in hospital-acquired infections. I argue that workplace reforms must play a key role in any attempt to control the spread of infections. To protect the patients, you first have to protect the workers.

Outsourced Workers, Unintended Consequences Clean hospital environments are critical for reducing hospital-acquired infections. Yet hospitals in many parts of the world continue to slash the resources dedicated to support services. Indeed, many are now handing over cleaning and food service responsibilities to outside companies, mostly local franchises of multinational corporations. Think McDonalds but with housekeepers instead of hamburgers. This is a particularly pernicious example of franchise capitalism— by transferring these jobs to outside contractors, hospitals are not just hurting their support workers but also increasing the risks to their patients. Unfortunately, hospitals are increasingly unwilling to spend the money to support the workers on the front lines of the fight against germs.33 As recently reported in the Canadian Medical Association Journal, “budget cuts and outsourcing have seen the proportion of hospital budgets devoted to support staff drop from 26% in 1976 to 16% in 2002.”34 These cuts mirror disinvestment in support services by U.S. hospitals, which are estimated to have reduced cleaning staff by at least 25 percent since 1995.35 Pia Davis, a representative of the Chicago Service Employees International Union, says hospital cleaners are barely prepared to do their jobs. “Hospitals hire people and say just go in there and clean,” she says. “They don’t show them what chemicals to use or not to use. We have report after report showing that rooms are not cleaned every day.”36 U.S. hospitals have gutted cleaning staff over the years, a dangerous response to financial crises that have pushed as many as one-third of U.S. hospitals to the brink of bankruptcy.37 Approximately one-third of American hospitals have outsourced their cleaning services.38 Disinvestment in cleaning has consequences: approximately 75 percent of U.S. hospitals have been cited and sanctioned for cleanliness and sanitation violations in that period.39 While public health officials are sounding the alarm about the spread of infection in hospitals, the workers responsible for keeping hospitals clean continue

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to toil in obscurity. If anyone talks about them at all, it’s usually in a quest for a useful scapegoat. But the workers aren’t the villains in this story; they are some of the real victims. Contracting out services can lower costs—at least in theory—but the savings come at a steep price. Housekeepers and dietary aides in hospitals are deeply aware of something that hospital administrators have refused to acknowledge. In many interviews, workers told me that outsourcing has led directly to dirtier, more dangerous hospitals. Hospital support staff require proper qualifications, training, equipment, and decent work conditions to do their jobs well, but outsourcing has undercut the workers and their mission at every level.40 The findings of my research reinforce previous studies on outsourcing and hospital restructuring. In the short term, these reforms create a great deal of stress and disruption for hospital staff, but in the long term, promised gains and efficiencies often simply fail to emerge.41 At the same time, outsourcing causes lasting damage to the quality of patient care. The consequences aren’t just theoretical. In a 2009 study, Dr. Robert Stanwick concluded that the plight of outsourced hospital support workers at a Vancouver Island hospital helped fuel outbreaks of hospital-acquired infections, including an extremely dangerous strain of C. difficile.42 Infection-control researchers have pointed to improper cleaning, crowding, understaffing, and high workloads as the cause of many outbreaks in hospitals internationally.43 When restructuring results in fewer nurses per patients, shorter patient stays, overfilled hospitals, and overstressed workers, you have a blueprint for trouble. Considerable attention has been paid to the effects of restructuring on doctors and nurses in hospitals, but the experiences of support workers have largely been ignored. Nevertheless, some of the impacts—increased stress, greater pressure, declining quality of work—are felt throughout the hospital.44 But some of the consequences for cleaning staff and other support workers are uniquely severe.45 Because of low wages, poor benefits, instability, and poor working conditions, hospital support jobs can be hard to fill, and contractors often have difficulty retaining existing workers.46 Although hospital administrators and governments may have hoped to achieve cost savings and improve services with outsourcing, there are often unexpected costs that result directly from understaffing, communication challenges, and reduced quality of service. At a broader level, the outsourcing of hospital and health care cleaning and similar support jobs exemplifies the trend toward low-road service-sector jobs that threatens to undermine social health, not to mention the physical health and well-being of patients in health care settings globally. Health care is a large and important sector of the economy, and when it begins to pay employees poverty wages, it contributes to growing inequality and all the consequences that follow.47

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The Outsourced Hospital Support Workers Study To see for myself how outsourcing was affecting patients and workers alike, I spent three years following hospital cleaners, dietary aides, and other support workers in Vancouver, Canada, where support jobs were outsourced in late 2003 and 2004. I discovered hardships and dangers that the politicians evidently never imagined when they set outsourcing into motion. In fall 2003, the right-of-center British Columbia provincial government in Canada tore up the existing collective agreements for hospital support staff, signed by the previous left-of-center government. This previous contract included wage hikes and benefit improvements typical of collective agreements; hospital cleaners then earned a somewhat higher hourly wage than unionized hotel housekeepers and had better benefits. New legislation led directly to the outsourcing of all of the hospital cleaning, food service and other support jobs in Vancouver and Victoria primarily to three major multinational corporations.48 Under Bill 29 legislation, ironically titled the Health and Social Service Delivery Improvement Act, 8,500 in-house hospital workers lost their jobs.49 These included hospital cleaning, food service, and other support workers as well as supervisors affiliated with the Hospital Employees’ Union (HEU) and the British Columbia Government and Service Employees’ Union. Some of these laidoff support workers were rehired to work in their old job positions by the new private sector contractors, but their hourly wages were set at little more than half of their previous wages. Prior to outsourcing, the median housekeeper wage was $18.32 per hour. After contracting out, housekeepers began at $9.50 per hour.50 These contract workers were no longer even considered employees of the health care system, despite working daily cleaning hospitals and serving food to patients. Although they have a contractor supervisor on site, they could no longer respond to direct requests made by health care staff, including nurses, who now had to contact the off-site private company call centers to request housekeeping and food services. At the time, outsourcing was justified as a necessary cost-savings measure, essential for freeing up resources for other important health care objectives.51 According to Jane Stinson, researcher, what followed was the “biggest wave of privatization in Canada’s history.” The provincial government and health authorities argued that hospital support workers weren’t much different than typical hotel housekeepers and other food services workers. But that comparison is flawed. Not only are hospital support jobs much more difficult, dangerous, and dirty than typical housekeeping and food service jobs, they also play a central role in the quality of health care and patient safety in hospitals. Yet, after outsourcing, hospital cleaners and dietary aides earn far lower wages and have weaker benefits

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than unionized housekeepers at high-end hotels in Vancouver.52 With this new employment regime, the public health authorities responsible for administering hospitals in the southwestern region of British Columbia have joined many large institutions and organizations in North America—both public and private—in subcontracting cleaning, laundry, maintenance, and food service jobs to multinational corporations. The research presented in this book is based on recorded interviews with seventy hospital support workers and twenty-six physicians, nurses, and infection control professionals working in the Vancouver region as well as on behind-the-scenes observations at hospitals and in neighborhoods from 2007 to 2011.53 The goal of my research has been to understand the work conditions in these low-wage servicesector jobs as well as the consequences of outsourcing on employees, their families and communities, and the health care system.54 What did I find? From the perspective of the support workers interviewed, the outsourcing of these jobs has been a disaster. Many of the workers now report facing serious challenges making ends meet. The workers also express grave concerns in terms of the quality of work completed. They describe a lack of proper training, significant understaffing, high levels of stress on the job, and frightening levels of both injury and illness—all common features of low-road servicesector jobs. These are low-security jobs that pay less than a living wage and fail to provide decent benefits and work conditions. The negative consequences of low-road employment are particularly serious in the health care sector, where underpaid workers literally hold people’s lives in their hands. Over the past several years, the HEU, which represents hospital support workers in the province of British Columbia, has been able to successfully demand some improvements in wages and benefits through collective bargaining. Yet these workers still earn lower wages and have weaker benefits than they had prior to outsourcing, and their wages are well below the $19.14 per hour living wage for the Vancouver region in 2012.55 The numbers are telling. More than 70 percent of support workers interviewed report difficulty paying their monthly bills. Carmela Hilota is a fortythree-year-old Filipina hospital cleaner and dietary aide. She works two full-time jobs with two different hospital contractors. She says, “On the first of the month, I’ve got headache and all my accounts all negative. . . . Every month my account is negative.” At one point she worked three different jobs in attempt to bridge the gap. “I worked seven days a week . . . from six o’clock [in the morning] until twelve [midnight],” she says. “That is non-stop. I had a break for one hour. That is no day off at all, no life,” she says. Hilota had to scale back after only six months. “I stopped because I feel very, very weak and I got sick. So I stopped the other one, so I am just working two jobs now . . . because I cannot do it [any] longer,”

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she says. Hilota’s health has been greatly affected by stress; she has back problems and cannot give her two-year-old son the attention he needs. Hilota and many other workers live in overcrowded housing with multiple families. Some describe dwellings with leaky roofs or ceilings, plumbing problems, and poorly functioning heating systems. Others contend with rodent or insect infestations and broken stoves or refrigerators. Many are regularly unable to pay their rent on time. Outsourcing has also changed their experience on the job. Severe understaffing, high turnover rates, lack of training and experience, on-the-job injuries, and poor-quality work are commonly noted concerns. Of the hospital workers interviewed, 67 percent report that they are often or always working short-staffed, 81 percent indicate that there are not enough staff members to provide a goodquality service, more than half say that they are often or always too rushed to work safely, and a shocking 63 percent report regularly getting sick or injured on the job. These obstacles result in cut corners, sloppy work, and highly stressed workers. Peter Wu, a hospital housekeeper whose regular shift in the intensive care unit (ICU) runs from 7:00 a.m. until 2:45 p.m., reports that he is always too rushed to work safely and always has too much work for the hours paid. He describes a recent situation in which one patient was being transferred from the ICU to another ward upstairs to make room for the transfer of an even more gravely ill patient. “I have to get everything all ready at 2:30 p.m.,” he says. “I have to rush, rush. . . . [In] fifteen minutes, I can’t do it. There’s no way you can do all the room, all the bed. . . . there’s no time at all!” Fifteen minutes truly isn’t enough time. For comparison, room attendants cleaning in North American hotels generally spend thirty minutes per room.56 Even though hospital support jobs are considered and officially classified as low-skilled, that does not mean they don’t require skills and expertise. The workers themselves know that the job requires proper technique and training. They also understand the stakes. Angie Kristham, housekeeper, explains that “we have to clean the room properly, everything needs to be clean. If we didn’t clean properly, maybe other patient comes and he will get the germs and he will get sick.” Even more disturbing were discussions of how outsourcing has reduced the kinds of supplies available to cleaners at the hospitals. Even those who know what to do sometimes find they have to make due with the limited supplies on hand. As Paula Rozero, hospital housekeeper, says, “We don’t have the tools to work with either because they’re forever short of supplies. Sometimes I have one mop to work with. How do you do isolations with one mop? They say, “Wash it and use it.” . . . Why do you think we have so many breakouts right now?” Other workers described reusing cloths or disposable gloves between different rooms

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and jobs. This clearly creates new opportunities for workers to spread infections around the hospital. For workers, these jobs are now even more challenging and dangerous. Cleaners work with potentially hazardous chemicals, which helps to explain why the babies of female janitorial workers in the United States have some of the highest rates of birth defects of any occupational category.57 If they do not receive proper training, they can be exposed to toxic fumes and chemicals, not to mention the occupational hazards of repetitive stress and strain. Their jobs are very physically strenuous, especially for a workforce where most employees are middle-age women. Fifty-six percent of the respondents rate their job as a 7 on a scale of 1 to 7, where 7 represents “very heavy physical demands”; 90 percent rate their job as a 5 or above. The list of physical problems included repetitive stress injuries, strains, burns, fractures, serious vial infections, spikes in blood pressure, and needle sticks. In each case, they are expected to just “work through it.” Health care workers can also fall victim to health care–associated infections, especially when they aren’t following proper procedures. And because workers don’t have many sick days—and because company policies discourage them from using the days they do have—many support workers reported coming to work when sick. As dietary aide Colleen Lanta says, “When we’re sick, they’re just thinking that we’re making it up. I hate that. I hate that. And they even ask ‘Are you really sick?’ . . . Sometimes when you get up in the morning . . . your body is so tired, and you feel pain. . . . There are times when you don’t want to go to work because you really feel sick. For one day, they’ll ask you a doctor’s certificate, and the doctor asks $10. They won’t even repay you!” The hospital work environment also breeds insecurity and social isolation. Many contract workers dedicate so much time and effort to paid employment that they do not have time for their children or families, much less time to become involved in community groups such as churches and school committees. Their low wages force them to live in neighborhoods where their families must contend with greater social disorder and crime. Not surprisingly, employees come and go in droves, and employers have trouble recruiting and keeping good workers.

Increasing Infections, and Risk to Patient Safety So what has happened to hospital-acquired infection rates in British Columbia since the outsourcing of support services began in 2003? The Healthcare Associated Infections Surveillance in BC report uncovered some definite trends. While the number of new patient cases of MRSA had stayed fairly constant

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prior to outsourcing from 2002 to 2003, the number of infections soared from approximately 3,000 patients in 2004 to over 11,000 patients in 2007 before dropping slightly in 2008 and 2009. The trend in number of VRE patients also skyrocketed from fewer than a hundred cases in 2003 to over 2,500 in 2008 before declining somewhat.58 The increase in hospital-acquired infection rates has been much more dramatic in British Columbia than in other provinces in Canada that have not as extensively outsourced their support workers; for example, British Columbia now has the highest rate of C. difficile infections in the country.59 Hospital-acquired infections have become an increasing challenge, costing hundreds of millions of dollars annually in British Columbia just for cost of treatment, extra supplies, and increased length of stay, not including pain and suffering, loss of mobility, loss of productivity, or loss of income. Vincent Stevens, a hospital-based nephrologist says, “In Vancouver, an increasing numbers of patients now have become colonized with AROs [antibiotic-resistant organisms]. . . . I must say that I think it is a losing battle.” Olivia Jameson, a medical microbiologist and administrator at a Vancouver hospital says, “We’ve seen the waves of antibiotic resistant organisms. Patients who get health care related infections end up staying in hospital longer, require more resources, more testing, more drugs, more other ancillary treatments.” It is important to be clear: I am not claiming that the outsourcing of support jobs is the sole cause of the soaring rates of hospital-acquired infections. Clearly many complex factors are at play. Nonetheless, these trends are extremely disturbing. They also parallel the shocking increase in MRSA and other hospitalacquired infections in the United Kingdom in the aftermath of privatization and outsourcing of support jobs in the early 1990s. According to Steve Davies, in the journal Politics and Policy, in the United Kingdom, “Huge increases in MRSA rates in the 1980s and 1990s coincided with a halving of the number of cleaners,60 the introduction of competitive tendering and the outsourcing of many hospital cleaning services.”61 At the same time, “The number of death certificates mentioning C. difficile (the other headline HCAI [health care–acquired infection]) increased from 1,804 in 2003 to 8,324 in 2007, up by 28% between 2006 and 2007.”62 Experts confirm that awareness of hospital-acquired infections has not kept pace with the growing threat. Louisa Appleton, an infection-control practitioner at a Vancouver hospital, explains, “we have so many infections that are being passed through the system. . . spread is so prevalent in the hospital, and yet we are not doing enough as an organization or as a unit to deal with it.” She senses complacency: “I think it has almost become accepted. You come into hospital and you get MRSA or you get VRE because that is what happens when you come into hospital. I don’t think they realize that it is something that can be prevented

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and that we all have an impact on whether or not it is spread around. . . . People are not as aware of how serious hospital related infections are. I think staff are so overwhelmed by their job that that gets fallen by the wayside.” Hospital-acquired infections also bog down the operation of the hospital, creating a host of problems from backups and delays due to ward closures. Brian Johnson, a physician and professor of medicine in Vancouver, describes some of the impacts: “Whole long-term care facilities have been closed down by norovirus, wards have been closed down by C. difficile. You know, a one-off case of surgical site infection probably doesn’t change the OR [operating room] schedule for that day. But, if you have twenty-five cases then you are going to have a lot of problems. You are going to have to close hospitals.” Daniel Andersen, a senior administrator of an intensive care unit at a Vancouver hospital, argues the challenge posed by hospital-acquired infections will only become more serious as “complexity of care continues to increase, hospitals continue to admit patients with higher degrees of co-morbidities and vulnerabilities, and hence the use of antibiotics will increase. At the same time, the research and development of new antibiotic molecules continues to be not commensurate to the change and the pressure that we see.” Everyone should worry about the growing incidence and severity of hospitalacquired infections. As Atul Gawande, surgeon, public health researcher, and author, reminds us in The Checklist Manifesto, the average American has seven operations in his or her lifetime. And, amazingly, over 5 million enter the ICU— notorious hotbeds of infections—every year.

A Global Trend Outsourcing is a global phenomenon. Hospitals and health care organizations in many countries—including the United States, Canada, and Germany—have contracted out cleaning and other support work to large multinational corporations whose annual profits run into the hundreds of millions. (One company alone, Aramark, reported over $13 billion in annual revenue in 2011.) In Germany, 40 percent of health care cleaning and support work has been outsourced, with dramatic wage and benefit cuts for health care support workers.63 The shift from public- to private-sector delivery of support services has been most drastic in the United Kingdom. UNISON, the union representing 400,000 health care workers across the United Kingdom, estimates that, over the last two decades, the vast majority of health care services have shifted from public- to private-sector delivery. In the early 1990s, for example, workers employed directly by the National Health Service (NHS) provided 90 percent of health support

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services, while private firms delivered only 10 percent. By 2008, the balance had reversed. This shift began in the 1980s with the implementation of Compulsory Competitive Tendering (CCT), a reform to raise standards and efficiency in public services.64 By requiring institutions to outsource whenever private firms could offer a cost savings, the government hoped that competing contractors would raise standards and lower costs in a constant effort to outperform each other and secure future contracts. Before long, CCT was adopted by the NHS, resulting in a massive shift toward privatization.65 Against a backdrop of a climate of austerity, a number of multinational corporations seek new opportunities to expand their businesses through service contracts that replace public-sector employees with private-sector employees. Corporations lobby governments and health authorities both directly and indirectly to secure these contracts. While these decisions can appear to happen overnight, they are often preceded by a long period of lobbying, campaign contributions, and backroom deals.66 The growth and expansion of the global corporations that provide outsourced services is fundamental to the global push to move basic services from the public to the private sector. These corporate contractors pay employees far lower wages and provide weaker benefits than workers received before. The main incentive for contracting out hospital support services is often purported to be cost savings.67 In some cases, fiscal or budgetary crises do require immediate cuts, and it is often in moments of crisis that many government or private organizations turn to contractors.68 It is important to note that in most of these cases, with the United States being a major exception, funding for health services remains largely the responsibility of the government. What has changed is that these services are now being paid for by the public sector but delivered by the private sector.69 These decisions also represent a form of privatization, a handing over of public resources to private for-profit corporations. When announcing its decision to privatize and outsource hospital support jobs, Vancouver Coastal Health (VCH) estimated that it would save $13 million per year.70 Although this is not an insignificant level of estimated savings, it should be considered in the context of a $3 billion annual budget.71 In reality, these estimated cost savings have not been realized. VCH had to pay a legal settlement of $75 million to the HEU for illegally violating their collective agreement and to compensate laid-off workers, which negated any projected savings for at least a five-year period.72 Beyond legal expenses, the costs of treating the increasing number of hospital-acquired infections and paying for other problems, such as workplace injuries and errors resulting from inadequate training, have further eroded any potential cost savings from contracting out. Although the numbers are not publicly available, experts also report that the number of infections have

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also been increasing despite campaigns to promote hand-washing and other infection-control innovations. Nonfinancial factors often play an important role in outsourcing decisions. In some cases, advocates of contracting out have successfully argued that contractors can offer specialized expertise in food services or cleaning and will therefore provide a higher level of service than in-house staff.73 As we will see, these promises have also not been realized. In many cases, it seems that the decision to outsource services is significantly influenced by ideology and politics.74 As Bruno Biais and Enrico Perotti, economists, argue in the American Economic Review, “Privatization can be used in a Machiavellian fashion, i.e. as a strategic policy to retain power. By allocating significant share ownership to a targeted section of the population, strategic privatization can build political support for right-wing parties.”75 For example, when provincial government legislation resulted in the outsourcing of hospital support jobs in southwestern British Columbia, it struck a painful, strategic blow to its political opponent, the powerful HEU. Outsourcing also has the advantage of helping employers avoid or eliminate unionization. Research on call centers has repeatedly demonstrated that employers choose to outsource with the explicit aim of avoiding collective agreements with unions or work councils.76 Given the fact that outsourcing isn’t really much of a money saver, this may be one of the true motives behind reform. In British Columbia, the HEU reports now coping with contract flipping, a process by which each time a contractor wins a new contract (replacing another contractor), the new contractor tosses out the previously signed collective agreement with workers—resetting wages and benefits to the legal minimums. The union then has to reorganize these workers and initiate a new round of negotiations for another collective agreement, eroding workers’ wages and benefits as well as job security. Organized labor represents a powerful counterforce to outsourcing, at least in theory. But even when unions are not entirely eliminated, they are often placed in a difficult position. Although they oppose outsourcing on an ideological level, they also have to be pragmatic when confronting the near impossibility of preventing or rolling back privatization. In many cases, instead of focusing on organizing against outsourcing, unions have been forced to negotiate with private-sector firms to protect the interests of their members.77 Although outsourcing does not often produce the promised savings or enhanced expertise in service delivery, one thing it does do is increase the number of low-wage, precarious jobs. Due in large part to economic restructuring, advanced economies are experiencing an explosion of low-wage service-sector jobs.78 For example, in the United States, nearly one in four workers earns less

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than $10 per hour, which puts workers well below the poverty line if they are trying to support a family of four.79 The rapid expansion of low-wage servicesector work has reshaped the economies of the United States, Canada, and many European countries.80 Many low-wage workers are even worse off than their wages might suggest. Because they are the first to be fired or have their hours cut, their earnings often fluctuate dramatically. As David K. Shipler explains in The Working Poor, “By measuring only income and expenses during a current year and not assets and debts, the formulas ignore the past and, the past is frequently an overwhelming burden on the present. Plenty of people have moved into jobs that put them above the threshold of poverty, only to discover that their student loans, their car payments, and exorbitant interest charged on old credit card balances consume so much of their cash that they live no better than before.”81 The working poor often live in crowded or run-down housing and even experience hunger despite earning incomes that are near or even somewhat above the poverty line.82 Others teeter on the precipice of hardship, living paycheck to paycheck, relying on credit cards and limited or nonexistent savings. Against this backdrop, influential corporate lobbyists and management consultants continue to convince organizations, institutions and governments to turn over control of public services to private firms. Targets for outsourcing have included the military, education, and health services.83 Outsourcing disproportionately affects the most vulnerable members of the workforce, including immigrants, ethnic minorities, and women. Recently arrived ethnic-minority immigrants to the United States, Canada, and other wealthy countries are at high risk of joining the ranks of the working poor because they face unique barriers to finding secure employment. These barriers include a lack of language fluency, unrecognized foreign work experience and credentials, limited social networks, and discrimination.84 From the sweatshops of Los Angeles to the non-unionized meat-processing plants of the Midwest, minority immigrant workers toil in difficult, dirty, and often unsafe working conditions for low wages. Immigrant women are the most severely disadvantaged workers in the labor market, and they most directly feel the brunt of privatization.85 Growing economic inequality threatens to reverse many of the gains in the struggle for gender equity by driving down women’s wages.86 In most developed countries, women enjoy higher levels of pay and lower levels of discrimination in the public sector than in the private sector. Thus, contracting out contributes to increasing gender inequality in the labor market.87 Outsourcing also threatens the health, quality of life, and material security of the workers in these jobs. By increasing women’s vulnerability in the labor market, these reforms also increase pressure

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on working-class families and communities, and compromise their standard of living and the context in which their children grow up.88 Fundamentally, in a hospital, outsourcing results in a loss of communication, cooperation, and teamwork. By breaking up the team, contracting out creates daily frustrations and dangerous miscommunication between nurses and other in-house staff and contract workers. When cleaners are not employed in-house, nurses can no longer directly ask cleaners to complete tasks. Working for a contractor also results in lower levels of employee commitment, more confusion, and divided loyalties, especially in the often chaotic and stressed environment of a hospital. When health care administrators decide to contract out cleaning services, they essentially hand over control of one of the most important levers for preventing and containing outbreaks of hospital-acquired infections. They no longer control hiring, training, retention, and even staffing levels—all critically important factors for infection control. As a result of these consequences, even if policies improved the wages and benefits for contracted out workers, outsourcing hospital support staff—especially cleaners—remains extremely problematic from the perspective of patient safety and outcomes.

Reversing Outsourcing In response to these challenges, some hospitals and governments are bucking the global trend toward outsourcing hospital service work. The world leader in preventing hospital-acquired infections, the Netherlands, employs in-house hospital cleaners.89 As does Denmark.90 The Scottish Parliament announced a ban on further outsourcing of hospital cleaning work in response to a serious bacterial outbreak linked to poor hospital hygiene in 2007–2008.91 It also ordered the nonrenewal of all current outsourced contracts after they expire and hired 1,000 additional hospital cleaners. The goal was clear: by putting the hospitals back in charge of their own cleanliness, the parliament hoped to reduce the rate of hospital-acquired infections.92 More recently, Scotland has been joined by the governments of Wales and Northern Ireland, which have announced the phasing out of contracting out hospital cleaning services and the hiring of additional hospital cleaners.93 The government of Spain has also instituted policies to reverse privatization and bring some health care services back in-house in response to increasing health care–associated infection rates.94 As we will see, outsourcing is not the only approach to dealing with resource constraints. Short-term savings in the area of hospital hygiene can lead to longterm costs and challenges. Indeed, my hope is that my research will serve as a warning to hospital and health authority administrators, union leaders, and

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policymakers about the devastating consequences of the decision to outsource these jobs—for workers, for patients, and for communities. The findings also clearly point to policy recommendations, which, if implemented, can help mitigate or even prevent some of these disastrous consequences of outsourcing for workers and patients. Looking deeper, the hospitals of today have become emblematic of broad societal themes: the relationship between work conditions and work quality, the social exclusion of ethnic-minority immigrants, and the lingering problem of inequality and social stratification in our most important institutions.

2 GERMS, BLOOD, AND COST-CUTTING The Daily Struggle to Keep Hospitals Clean

If you want to find the most germ-ridden building in any city, head straight for the hospital. Not even the grungiest day care center or locker room can match the bacteria and viruses that float through hospital hallways, cafeterias, and even operating rooms. After every major outbreak, microbiologists and infectioncontrol specialists descend on the scene to find the source of the infections. Time after time, they reach same conclusion: the hospital simply isn’t clean enough. Experts in public safety have recognized for years that hospitals have a serious hygiene issue. They have interviewed doctors, provided extra training for nurses, and set up hand-sanitizing stations, all in an attempt to bring infection rates under control. But few have ever taken a close look at the people on the front lines of hospital cleanliness—the workers in charge of mopping floors, wiping down countertops, and disinfecting doorknobs. In an age of budget cuts, many hospitals are saving money by outsourcing their cleaning staff to outside companies that don’t necessarily have a hospital-grade dedication to hygiene. Contract workers are often underpaid, undermotivated, and overworked—a combination that could have dangerous consequences for patient health.

Outsourcing Hospital Support Services To understand the problem of hospital outsourcing, we have to first understand how the industry works. Cleaning in a hospital that maintains its own housekeeping staff functions in the following manner. The hospital employs a 19

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complement of housekeeping staff that it hires, trains, and updates and to which it furnishes cleaning supplies. A supervising staff under the department of environmental hygiene manages the housekeepers. This staff is in regular contact with other floor nurses and their managers, who assess that most rooms are cleaned. Decisions—when to clean, what to clean, how to clean to prevent infections, how to properly disposal of used gowns and gloves when a patient has a serious contagious infection, and how to encourage hand-washing—are discussed and implemented in-house. But with hospital outsourcing, this in-house process is entirely dismantled. First, the in-house cleaning staff is fired. So are their managers and educators. Afterward, some may be rehired, but others will be replaced by workers who have had no connection to the institution or hospital or health care whatsoever. When staff or housekeepers are hired, the new employer—the contracting cleaning firm—rarely replaces or rehires the full complement of staff or supervisors employed previously. So, if hospital had three cleaners per ward, the shift will now have two or less to complete the same work. (Note that neither the supervisor nor the cleaner now works for the hospital.) The education and training of staff (and proper cleaning does require education) now is the responsibility of the contracting company. So is determining what is supplied and how much is provided to staff. When later in the book I refer to workers’ problems with managers and supervisors, I am not talking about the in-house hospital management but, rather, the contracting companies. Cleaning staff workers officially no longer have direct contact with the nursing staff and nursing managers. Instead, their contact is mediated by the contracting company. So, if a nurse has a problem with the cleaning of a patient room or needs a room cleaned, she can no longer speak directly to the cleaner; instead, she has to call (or her manager has to contact) an off-site call center, which then pages the on-site contractor supervisor, who has to be tracked down, to address the issue with the cleaner. These changes are occurring at the same time that increasingly resistant hospital-acquired infections threaten patient safety.

Hospital-Acquired Infections To understand the importance of clean hospitals, we first have to understand the threat, namely the viruses and antibiotic-resistant bacteria that are showing up in hospitals across the world. Mutations, natural selection, and microbial evolution partially explain the emergence of new strains of bacterial and viral pathogens. Yet humans have helped set these biological mechanisms in motion. For example, the overprescription of antibiotics and the widespread use of powerful

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antibiotics in factory farming breed the very type of resistant bacteria that shows up in hospitals.1 Once bacteria reach the hospital, they spread easily from one surface to another.2 They can even make their way into the ventilation system, giving them an airborne entryway to the rest of the hospital.3 Here is a look at some of the superbugs that are making the rounds in hospitals.

Methicillin-Resistant Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) is an especially common and dangerous infection that, in some cases, turns out to be untreatable.4 As the name suggests, it’s virtually impervious to methicillin, once the go-to antibiotic for staph infections. As a result, doctors have to scramble for other ways to kills the germ, and they don’t always succeed. Researchers at the U.S. Centers for Disease Control have estimated that MRSA kills 19,000 Americans every year, making it more deadly than the human immunodeficiency virus (HIV).5 The germ kills about one in five patients (with approximately 90,000 Americans getting infected each year), and some victims are young and otherwise healthy. MRSA infections often start in small nicks or scrapes in the skin. The infection can look like a small red bump; at first, many victims think they have a spider bite. Once it gains a foothold, the germ can burrow deep into the tissue, attacking bones, joints, and anything else it can reach.6 For hospitalized patients who are already battling illnesses, a case of MRSA can easily prove to be the final insult. Fighting MRSA is an expensive business. The total cost of treating MRSA infections in the United States is estimated to be $3–4 billion annually.7 In Canada, the average cost to treat each MRSA patient is between $16,836 and $35,000.8 Once MRSA has found its way into a hospital, it is very difficult to eliminate. A single infected patient can contaminate entire floors, often because nurses and staff inadvertently spread the germ through contaminated uniforms, equipment, or cleaning supplies.9 A study in Norway estimated the cost of decontaminating a neonatal intensive care unit (NICU) at US$54,000 per infected patient.10 The good news is that in 2010, the U.S. Centers for Disease Control reported that cases of MRSA infections in hospitals and other health care settings in the United States had dropped about 9 percent every year from 2005 through 2008.11 Still, the rates remain dangerously high, especially compared to rates in northern European countries. Nobody knows exactly why the numbers of MRSA infections are on the decline in U.S. hospitals, but the crisis undoubtedly resulted in some improved infection-control surveillance, programs, and policies. At the same time, experts around the world have identified several factors that could re-ignite the epidemic. The U.S. Centers for Disease Control National Institute

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for Occupational Safety and Health has highlighted five potential triggers: “crowding, contact, compromised skin, contaminated items and surfaces, and lack of cleanliness.”12 The United States isn’t the only place where hospitals seem to be making headway against MRSA. Norway, Denmark, and Sweden, countries that have successfully employed a search and destroy tactic to counteract the infection, have much lower levels of MRSA infection than the United States.13 Patients and hospital workers are screened regularly, and anyone found to be infected is isolated and treated. This practice is expensive, but it has dramatically reduced serious illness and infections in these hospitals. This approach has been so effective that the handful of cases found each year in Norwegian hospitals tend to be mild and are often imported from other countries. In a country with a population of 4 million people, only 144 cases of MRSA were detected in Norwegian hospital patients in 2006.14

Clostridium difficile C. difficile is a virulent bacterium that continues to develop ever more lethal strains. One U.S. study found that patients infected with C. difficile are three times more likely to die than similar uninfected patients.15 Symptoms range from mild diarrhea to debilitating and potentially fatal inflammation of the colon. It is estimated that nearly 10 percent of people who are infected with C. difficile in a hospital develop serious complications, including dehydration, perforated bowel, and gastrointestinal bleeding. Of these serious cases, about one in five prove to be fatal.16 A relatively new strain of C. difficile, called NAP1, has taken the threat to a new level. It produces fifteen to twenty times more toxins than the more common strain of C. difficile and kills up to 17 percent of infected patients.17 This lethal pathogen has been discovered in hospitals in forty U.S. states, all the Canadian provinces, and several European countries.18 An outbreak of this strain of C. difficile killed as many as 2,000 patients in the province of Quebec alone from 2003 to 2004 before it was brought under control.19 C. difficile NAP1 has also taken its toll the United Kingdom, where the number of people killed by C. difficile infections rapidly increased by 72 percent from 2005 to 2006.20 Of all of the different types of superbugs, C. difficile is especially likely to thrive in unclean hospitals. Without proper cleaning, the pathogen can linger for extended periods of time on sheets, floors, toilets, and other surfaces.21 Unlike many other germs, it doesn’t die when its environment dries out. Instead, it forms a spore and waits for a chance to revive.22 These spores can spread across hospitals on contaminated equipment and the hands of health care workers.

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Alcohol-based hand sanitizers are less effective against C. difficile, especially spores. Hand-sanitation campaigns—although effective against most germs— have a limited impact on C. difficile transmission in the hospital. An infectioncontrol practitioner at a Vancouver hospital explains, “C. diff. is a clever little organism, so it has vegetative bacteria and it has the spores. The spores have a hard waxy shell, and they live quite happily in alcohol. It is not killed like a lot of the organisms.” Either a 1:10 bleach solution or an accelerated hydrogen peroxide solution can kill the spores, but hospital cleaners don’t always take this crucial step of washing rooms, equipment, or themselves during an outbreak.23 Funding cutbacks and the outsourcing of housekeeping and support services have ramped up the danger of this already menacing infection. As Michael Libman, head of infection control at the McGill University Health Centre puts it, “There is little doubt housekeeping budget cuts and nursing shortages contributed to difficulties in controlling the spread of the new strain of C. difficile.”24

Other Emerging Threats Vancomycin-resistant Enterococcus (VRE) is another antibiotic-resistant bacterium that can infect hospital patients, especially those with weakened immune systems. This bug is resistant to the antibiotic vancomycin, making it very difficult to treat. VRE can survive on surfaces for up to four months and is extremely difficult to eliminate.25 Standard “terminal” cleaning routines, which are the tasks completed when a patient vacates a room, are not enough to wipe out VRE.26 One U.S. study found that only a four-hour intensive cleaning procedure, in which disinfectant remained in contact with the bacteria for an extended period of time, was sufficient to kill VRE.27 The roster of dangerous bacteria in hospitals also includes Acinetobacter baumannii, which causes bloodstream, urinary tract, and wound infections that cannot be cured with common antibiotics,28 and Escherichia coli, the common intestinal germ. Most E. coli infections are treatable with a broad range of antibiotics. Some new strains of E. coli, however, are resistant to many drugs, resulting in hard-to-treat infections of the bladder, urinary tract, digestive tract, kidneys, and, in some cases, blood.29 Patients infected with particularly virulent strains of E. coli can develop potentially fatal hemolytic-uremic syndrome (HUS), in which toxins from the infection destroy blood cells and damage the kidneys. The conditions are already ripe for the emergence of new strains of resistant pathogens that could take an unprecedented toll on hospitals and the community at large. Vancomycin-intermediate/resistant Staphylococcus aureus (VISA/ VRSA) infections are still relatively rare, but too many hospitals are leaving

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the door open for an outbreak.30 And then there’s an emerging class of germs that really has experts frightened—pan-drug-resistant gram-negative bacteria (including E. coli and Klebsiella pneumoniae) that can withstand practically every antibiotic known to medicine.31 The U.S. Centers for Disease Control has also begun tracking carbaperiem-resistant Enterobacteriaceae (CRE) and multidrug-resistant (MDR) Acinetobacter, which are resistant to virtually all antibiotics.32 Then there are the viruses. The norovirus is transmitted through personal contact or contact with contaminated surfaces, food, or water.33 The virus— which causes nausea, followed by projectile vomiting and diarrhea—has infected an increasing number of people in nursing homes, in hospitals, and on more than a few cruise ships.34 The much-feared severe acute respiratory syndrome (SARS) virus—which caused a near worldwide panic after spreading from China to cities around the world in 2003—also proved that it could linger in hospitals and spread to other patients and health care workers.35 The germ seems to be on hiatus as far as humans are concerned, but it could easily make a comeback. Public health experts are also worried about the future evolution and potential catastrophic global epidemic of H5N1 “avian” flu.36 The experts concur that the challenge of hospital-acquired infections is poised to become much more serious as increasingly deadly strains of resistant superbugs emerge in the community and make their way into hospitals.37 As Louisa Appleton, an infection-control practitioner working at a Vancouver hospital says, “Superbugs are becoming more resistant with all the antibiotics we use with them and the different strains mixing. We are just getting a lot of organisms we wouldn’t normally see here in Canada and vice versa. People are coming from Canada and going to other countries and the same thing is happening as well. We were getting some from Greece and from other countries as well that are highly resistant.” Globalization, mutation, and increasing resistance portend many frightening developments as health care–associated and community-acquired pathogens threaten the health of and recoveries of an increasing number of people.

The New Challenge: Preventing and Treating Increasingly Dangerous Infections Without comprehensive reform, the severe threat posed by health care–associated infections has the potential to quickly become much worse. Arthur Sanders, senior faculty member and leading expert on infectious disease, sees trouble ahead:

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I think we are going to see more emerging infections in the hospital setting with run of the mill organisms because of antibiotic resistance. . . . When things don’t work and someone gets infected with a resistant organism, and we have to use a crutch of antibiotics to try and bring that under control, as we lose the crutch of the antibiotic, then we’re going to lose that end of the spectrum in terms of ability to keep things under control. . . . We are going to be generating more and more very hard to treat organisms that we won’t eradicate from patients. As Brian Johnson, a physician and professor of medicine in Vancouver, explains, the problem isn’t going away soon: “The excessive use of antibiotics when they are not needed, the organisms’ ability to evolve—I’m sure we’ll see this on the agenda for a long time.” Scientists are working to develop new antibiotics, but it is foolhardy to hope that innovation alone will solve the crisis. In the realm of antibiotic research, it has been said that “all the low hanging fruit has now been picked.”38 Shockingly, few scientists or pharmaceutical companies are even researching or developing new antibiotics to counter the emerging threats. Any progress from here on out will be incremental, expensive, and unlikely to significantly turn the tide for long. As is so often the case, the prevention of hospital outbreaks would be much more effective and less costly than reacting after the fact. A failure to act now not only increases the likelihood of more health care–associated infections, it also increases the risk that superbugs will spread beyond the confines of the hospital and into other community institutions such as day care centers and schools.

Preventing Health Care–Associated Infections: Why Proper Cleaning Matters When researchers search for underlying causes of infectious outbreaks in hospitals, they almost always find serious shortcomings in hygiene and cleaning. A deadly outbreak of C. difficile in Canada prompted this response from the British Columbia Center for Disease Control: “The spread of infection in healthcare facilities can be prevented by strict infection control practices (especially meticulous hand hygiene, appropriate use of gloves, and proper cleaning and disinfection of environmental surfaces and patient care equipment) and conducting surveillance for new cases and promptly isolating and treating identified cases.”39 Hospitals don’t need to simply be “clean” in the normal sense of the word—they have to be disinfected. Cleaning without disinfecting is not only ineffective, it can exacerbate the problem by spreading germs around the hospital

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on contaminated mops, sponges, gloves, and other cleaning supplies. Specialized cleaning procedures, such as the use of hydrogen peroxide vapor or ultraviolet (UV) radiation, for example, have been shown to be more effective in eradicating MRSA than standard cleaning practices.40 Specific cleaning times and temperatures for laundry and disinfecting bedpans are also crucial.41 In hospitals, cleanliness starts with cleaners. It takes the right skills, training, and management to keep infections in check. Despite their critical role in infection control, cleaners are a low priority in many hospitals. In industrialized nations, tasks such as cleaning and food preparation are associated with unpaid and unskilled labor, even when these jobs are a matter of life and death. As described in chapter 1, the research evidence clearly shows a link between environmental contamination and hospital-acquired infections. Mark Smith, an infection-control expert in Vancouver, says that, when it comes to reducing the rate of hospital-acquired infection, “The guy who cleans the toilets is just as important as the important as the physician who washes his hands before he does surgery.”42

The Disastrous Consequences of Cuts to Health Care Services Outsourcing hospital support jobs is one example of the erosion of both funding and regulatory oversight in the public sector. Despite increases in revenue, the growing demand and need for services have left many hospitals in North America struggling financially, resulting in a climate of austerity in which regular restructuring and other cost-saving measures have become commonplace. According to survey data collected by the American Hospital Association, the number of hospitals in the United States has declined by 14 percent since the mid-1980s, resulting in an 18 percent drop in the number of available beds.43 Major cutbacks in federal health spending in Canada in the mid-1990s temporarily balanced the federal budget but also broke the long-standing commitment by the federal government contribute 50 percent of provincial health care expenses. This shifted a greater burden onto the provincial governments, where health care competes with education and other priorities for limited resources.44 Provincial governments in Canada, much like the cash-strapped U.S. states, have responded by attempting to rein in rapidly increasing health expenditures. These funding cuts and other reforms have come at a time when the North American population is growing older and sicker, and when there is a growing demand for expensive diagnostic and lab services and increasingly expensive prescription drugs. The strain on the system is palpable. With fewer hospital beds, ambulances are diverted from overwhelmed emergency rooms where patients wait for hours to see a doctor.

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Many hospitals in North America are now operating at near-full or overcapacity. According to American Hospital Association (AHA) data, 90 percent of large hospitals in the United States operate at or above capacity.45 Canada cut its number of hospital beds by 36 percent between 1998 and 2002;46 by 2005, bed occupancy rates had soared to 95 percent.47 Not surprisingly, hospital infection rates also increased over the same period. For instance, St. Paul’s Hospital in downtown Vancouver regularly operates at between 95 percent and 105 percent of operating capacity.48 That may not sound dramatically overcrowded, but studies show that anything above 75 percent greatly compromises infection control.49 When a hospital goes over the 75 percent mark, some patients who should be isolated because they are infected with MRSA or another pathogen have to start sharing rooms (and potentially germs).50 A recent study in Lancet Infectious Diseases found that high rates of patient turnover in hospitals coupled with understaffing make patients more vulnerable to MRSA infections.51 Crowded hospitals often rush to send patients home before they have been fully evaluated for infection, meaning patients are bringing infections home and into the community. In many cases, patients sent home with an undetected infection come back to the hospital with a full-blown case that’s impossible to overlook.52 Crowded hospitals also tend to have overpacked emergency waiting rooms. These holding pens of the sick and injured can be the most germ-ridden and undercleaned part of hospitals. Following a recent outbreak of C. difficile at a British Columbia hospital, outsourced cleaners admitted that they rarely disinfected the emergency room (ER) waiting room for one simple reason: it was always too full of patients.53 The fiscal climate of austerity and administrative zeal for cutbacks and restructuring generally makes hospitals less safe. Lower staffing levels, higher patient turnover, and crowding plus rushed, exhausted, and overworked health care workers plus outsourcing and disinvestments to environmental hygiene add up to the transmission of increasingly difficult-to-treat infections from which some patients don’t recover.

High-Stakes Multitasking Hospital support workers clean and sterilize post-operative surgical rooms. They sanitize patient rooms, including special isolation rooms occupied by patients with infectious diseases. They collect and dispose of used needles, bloody bandages, and other biohazardous waste. They prepare and deliver meals for patients, many of whom have specific dietary needs. Despite the critical importance of these jobs, hospital service workers often toil in near obscurity. In her gripping book Hospital, Julie Salamon, former

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New York Times reporter, chronicles a first-year resident’s impressions of Maimonides, a hospital in Brooklyn. The book parallels the excitement and drama of popular TV series such as ER and House. Yet, as in these TV shows, cleaners, dietary aides, and other support workers remain invisible. Her three-page listing of the cast of characters includes everyone from the chairman of the board to patients to the “director of outreach to Asian community,” but housekeepers and other support staff are nowhere to be found. Such anonymity has made it easy to outsource hospital support jobs. The story of the mass contracting out of hospital support jobs in British Columbia is perhaps surprising to those who think of Canada as a bastion of social justice and good governance. The Canadian universal health care system is held up by many progressive Americans as a model of equity and cost efficiencies. Also, the province of British Columbia is known for its strong unions and generous social policies. That’s why this region is such an important case study: if hospital housekeepers can be pushed to the margins here, it can happen pretty much anywhere. Hospital cleaners and other support workers complete critically important jobs in the health care system. For example, the job of a hospital housekeeper can range from disposing of body tissue in post-operative surgery rooms to cleaning up blood splatters, feces, and vomit.54 Yet their work is highly devalued and largely invisible to the public and policymakers as well as to health care professionals and researchers. Improving infection control in hospitals requires recognizing the important work completed by hospital support workers and finding ways to improve their training and working conditions. There’s more to quality health care than successful surgeries, accurate diagnoses, and effective prescriptions. In the big picture, health care requires prevention and long-term recovery, which in turn depend on a clean environment and service-oriented staff. Even in countries such as Canada, with its much-vaunted universal health insurance, health care systems put far too much emphasis on treatments and cures and far too little on disease prevention.55

Who Works in Hospital Support Jobs? The largest groups of hospital support workers are housekeepers, who clean patient rooms, operating theaters, public areas, and offices. The rest are food service workers, who prepare and deliver food to hospital patients. The majority of these are dietary aides whose duties include working the food-assembly tray line, delivering food to patients, and kitchen-related tasks such as dishwashing. A few support workers hold more specialized roles, such as cooks. In conversations

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with these workers, I learned that these jobs are much more complex, challenging, and multidimensional than their titles, status, and pay suggest. In Vancouver, hospital support jobs are most often filled by ethnic minorities, immigrants, and refugees, with the largest group from the Philippines. Others come from China, India, Vietnam, Sri Lanka, Somalia, and other corners of the globe. The overwhelming majority of support workers are female.56 Unsurprisingly, many of hospital support workers decided to come to Vancouver with the hopes of securing a better quality of life. Freda Bansal, a fiftyseven-year-old Filipina housekeeper, describes her family’s decision to immigrate to Canada: “I came here [because] in my country the medical system is not very good. I had a younger sister, she just had the flu, and she died. Then I had another brother, he poked his ears and [got a] tetanus infection. They couldn’t heal him. The day my dad was taking my brother to New Zealand for an ear operation, he had everything arranged, and the same morning my brother died. So then my dad said, ‘I don’t want my kids to live here anymore.’ ” Despite their hopes and dreams, many have struggled after arriving in Canada, in part due to challenges created by precarious employment. Amarita Kohli is a fifty-five-year-old Indian mother of four children who immigrated to Canada in the late 1970s. She explains, “I came here for the regular living, so thank God he gave me this chance to live in this beautiful country. I’m happy here.” When they arrived, her husband would not allow her to get a job and, instead, insisted that she stay at home to raise their children. “I was like, ‘I want to go and make more money and [provide a] better life to my children.’ . . . So then I decided to go to work.” Kohli, who holds an undergraduate degree from India, is currently working two hospital dietary aide jobs. One is attached to Alderwood Hospital and another is at a senior care center. The privately owned and operated senior care facility is paying her significantly higher wages at $18 per hour, compared to $13 per hour for her outsourced hospital job. In Kohli’s case, working just two jobs is a luxury compared to her previous situation. “Before I was working three places. I was working Mapleview Hospital, Alderwood Hospital, and at that time, I had a part-time job. I was working three places . . . [for] $10 dollars [per hour]. Then I have to find another job. I went Tremont Private Care again, so thank lord they hired me again.”57 Many former support workers were laid off and then rehired to do their same jobs for the private contractor after outsourcing, despite the dramatic reduction in wages and benefits. Chin Lan Shao, a fifty-seven-year-old housekeeper and immigrant from China, cleans the TB ward at Mapleview Hospital. Prior to contracting out, she had worked cleaning hospitals for nearly thirty years. “When they [started] contracting out in October 2003, we had to find another job. They asked us if we want to work for Regents, so from there, I got the job.” Prior to

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outsourcing in 2003, she earned $19 per hour; she continued to work the same job for $9.50 per hour. Some support workers feel their histories make them more vulnerable to exploitation in the labor market. Juan Laguatan, a fifty-four-year-old Filipino housekeeper, explains, “Most of the people in the hospital mostly come from the Philippines. We live [with] political oppression back there. Their background is oppressed. They are afraid. You cannot blame them.” He said that many workers fear they would lose their jobs if they made the slightest complaint about their working conditions.58 Many of the workers landed their hospital support jobs almost by accident. Some of them have previous health care training or experience; most do not. While they are unhappy about their levels of pay and benefits and their poor working conditions, they don’t see many other options in a bleak labor market. Yet many still have hopes of finding a stable job that will pay a living wage. Others are fighting to improve the quality of their current jobs with the hopes of getting back to what they once had before outsourcing. Hospital workers often carry a heavy burden on their shoulders. Many are expected not only to support themselves and their immediate families but also to provide much-needed resources to family members in their home country. They are frequently reminded that any extra resources they can send will make a world of difference—from providing life-saving surgery for an uncle or access to educational opportunities for relatives. Meanwhile, they are toiling for low wages in one of the most expensive cities in North America. So they sacrifice. They cut back, they work second and third jobs, and they scrimp and save. Many are also expected to complete a second or even third shift at home, caring for children, parents, or even the children and parents of the more privileged. In the face of economic hardship and job insecurity, they battle disappointment, frustration, isolation, loneliness, deprivation, and hardship. Yet these workers have not lost hope that things can and will get better.

Hospital Housekeeping: A Challenging and Important Job Housekeeping jobs, in general, are far from ideal jobs. Barbara Ehrenreich, in her classic book Nickel and Dimed, eloquently describes the physical strain and humiliation of being forced to scrub floors on her hands and knees in wealthy suburban homes. Hospital housekeeping features much of the demeaning and physically challenging aspects of cleaning work—but with additional concerns about toxic waste, germs, and biohazards. While a home housekeeper might confront a filthy toilet or a hotel housekeeper may encounter a trashed room, only a hospital housekeeper will, on a daily basis, clean up blood and human remains

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from operating rooms or scrub frequent spills of human waste, blood, and other bodily fluids of very ill people. As Tracy Melucci, housekeeper, puts it, “you’re dealing with people in beds and vomit and stuff, and nothing prepares you for that.” Melucci describes what it takes to do a terminal cleaning to prepare a room for a new patient. “You wash everything: walls, everything. Everything. That’s a terminal. When you’re using the wall washer and doing that, you’re doing four of them. Well, some can take an hour each. You go home in pain.” The job is physically demanding. Freda Bansal describes some of her daily job tasks: “There’s lots of heavy floor washing to do. And the garbage is so heavy. Some of these beds are very heavy to lift. The last time we weighed, some of those beds are like 45, 50 pounds. You have to really drag it. Because some of those blankets in the hospital are very, very thick and heavy.” Housekeepers must complete their heavy-duty tasks extremely quickly. Diana Mamaril, housekeeper, says that she and fellow housekeepers are the “line of defense against infections.” Unfortunately, they rarely have enough time to fully complete that line of defense: “[It is] too much because when there is too many patients the only thing that you can do is pick up the garbage, do a little wiping and dusting here, and that is it. Just the essentials, not the extra like working thoroughly from up and down, side to side. You don’t have that much time.” Cleaners must disinfect a variety of surfaces. Mark Pilande’s housekeeping schedule puts him in different departments on different days of the week. “It’s nuts,” he says. “Currently, Monday and Friday I work at the OR. Tuesday I work at another department doing [patient room] discharges. Saturday and Sunday I work at the ER—emergency.” Whenever a patient is discharged, he has to “clean the bed, clean the lines, clean the walls, clean the floors.” As he explains, “cleaning the lines” involves wiping down every IV line and any other tubes or wires that are connected to a patient. They must also regularly cope with emergencies. Outside of her regular assigned cleaning tasks on her floor, Diana Mamaril is sometimes paged by her supervisor to assist with special cleans or other situations. “When they are pulling us from our area to do other areas . . . they [say they are] are doing it because they are short-staffed and that particular area is important. Once, we did one in ICU when there was an outbreak, so they tell us that we have to sanitize the points. It involves vomiting and diarrhea. Infectious. Yes.” Cleaning the emergency department can be especially stressful, as Renata Patel, housekeeper, relates: I work in the emergency department. Every room, everywhere. The lunchroom, the washroom, everything. And lots of discharges. We never stay in one place because lots of people [come to the] emergency

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department, and they call every minute, “Housekeeping,” “Housekeeping,” and we have to go. Lots of times, the person is vomiting. Lots of bleeding on all the floors and areas. Sometimes the people pee there. Blood every time. We have to go every minute to clean up that stuff. Emergency is, oh my goodness, crazy. Only two ladies [working] there.

The Hazards of Hospital Housekeeping In addition to being physically challenging, cleaning can be downright dangerous. Accidents, violent patients, needles, and regular exposure to biohazards come with the job. In a 2004 report examining the consequences of outsourcing at the emergency department of St. Paul’s Hospital—a major downtown Vancouver hospital—a former housekeeper described the risks: The abuse that the drug-users gave the staff—I think that was the hardest. Saving people’s lives and then being told to f-off and actually spitting at you and throwing shit at you and all this nonsense. That used to happen down there and probably still does. As a unit, we all came in together and helped—including security, the nurses, the Ward Aides and the housekeeper—everyone came in and we were a unit. If they don’t have that there now, I would not feel safe working there. . . . It’s really scary to work there.59 Maria Ganpule, housekeeper, explains some of the many ways one can get hurt in the hospital: being hit by swinging doors, pinching a finger in a folding bed, falling down stairs, and even being stuck with a needle. Patients can also be dangerous, particularly in the psychiatric ward. “I had my hair pulled. I was slapped and scratched a couple of times,” Ganpule says. “Most of the time when they’re violent, we give the medication and tie them in the Gerri-chair. The beds have belts so they can’t get out.” Exposure to pathogens and harsh chemicals should also be part of the job description. Ruby Das, a forty-nine-year-old Indian housekeeper and mother of three children, coughs throughout her interview. When asked if she needed a drink of water, she responds, “No, no, no, I have allergy. It’s just the stupid Virox we use over there. I’m always like that.” Virox is a toxic chemical used for cleaning hospitals infected with MRSA. “Because of . . . MRSA, we have to use Virox on everything in the room we clean. Virox 100 percent kills the germ, like bleach, but there’s no smell. I’m in hell. It’s all the chemicals.” Das also describes getting frequent colds and even stomach flus because she works around ill patients. “It’s come and go. Last year I got [sick] for a time, and the summer I got better, and now again, it came back,” she says.

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Das finds that the emotional aspects of her job are even more difficult to cope with than the harsh cleaning chemicals. As she puts it, “You see people dying over there. It’s emotional, so emotional. It’s not happy job, [and you try to] close your eyes and ignore it. But you can’t! They’re human over there. And some of them, they’re young. One of them is a guy, he has MS [multiple sclerosis], fifty-two-years-old. You talk to them and it’s so emotional. They’re living there to die. They come there to die. They’re not coming there for getting better and going home. Especially on our floor.” Hospital housekeeping means regularly working with potentially dangerous infectious material, as Juan Laguatan, a single father of two teenage children, attests: “The worst is when you clean in a room [after] someone is discharged, someone is sick. Well, this the first time I have learned about the sickness part like MRSA and VRE. It’s really frightening. I think it’s risky because I am the only one—the breadwinner. So what happens to me [if I] get sick? [What] about my children? It’s too risky to work here in the hospital.” Beyond worrying about infecting family members and friends, many hospital cleaners feared that the repetition and strain required by their job put them at risk of debilitating injuries and illness.60

Food Service Patients need to eat, so every large hospital employs enough cooks, dishwashers, and delivery people to run several restaurants. Khalid Imani, a forty-three-yearold Iranian cook, says he prepares soups, vegetables, stocks, and sauces for about 1,400 people a day. It’s not like restaurant work, he says; “Well it’s a hospital, we have to do it their way. Because all the food we cook is prepared by dietitians. So we have to follow the recipes, those rules are not made by supervisor, but made by dietitians, to fit exactly the nutrient amount or these things for the patient.” These dietary guidelines can play an important part in patient treatment and recovery. Like many back-of-the-house food service jobs, dietary aide positions require physical stamina and strength to keep up with the demands. Suzanna Lopez, dietary aide, rates her job as a 6 on a scale of 1 to 7 in terms of physical demands because “We’re delivering the food. It’s inside wagon carts. We have to pick up those six wagons in only an hour, and we have to go to each room. And each room has four trays, so we have to go back four times and in each wagon there are 20 trays. 20, 40, 60, 120. We have to pick up 120 in an hour. So that’s really heavy. You have to push and pull that cart all over the floor of the hospital so it’s really heavy. And you must finish it in an hour.” Lily Oracio, dietary aide, puts it succinctly: “Too much work!” She continues, “It’s hard on your legs, it’s hard on your back. After work, that’s when you don’t

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do anything anymore. You rest to get ready for the next day. So you can function again the next day. You don’t go anywhere after work, so you don’t tire yourself, so you can work the next day.” Ida Bates, dietary aide, concurs: “In this kind of job, it’s mostly standing up, walking, carrying, and by twelve hours, my body is hurting.” Food service hospital jobs are not only tough but risky. Many workers tell workplace injury horror stories. Henry Chu, a fifty-six-year-old Chinese cook, was badly burned on the job. “My foot . . . the hot water from the steamer just exploded, came down. I think it’s a second-degree burn. . . . I usually do the same everyday, but that day, I don’t know why, but that day when I opened the steamer the water just came flushing out. They never found out what happened.” Chu received one week of paid sick leave to recover from his injury. Similar to hospital housekeepers, long-term employees in food services report that the actual content of their job routines did not change very much postoutsourcing. What did change was the pay, the benefits, and the pace—all for the worse. Although outsourced hospital support workers are no longer officially considered part of the health care system, most of them experience on-the-job hazards similar to other health care workers, including exposure to contagious diseases. When asked if she would like more time interacting with patients, Gaya Johl, a forty-two-year-old Indian dietary aide at Alderwood Hospital, replies, “No, then they make you more sick [laughs].” “I do a lot of coughing,” says Erika Koch, a sixty-three-year-old German housekeeper. “I have colds. [When] I was working the other jobs, sometimes I didn’t have [a cold] for two years. Right now, I do have colds. If you go in there and people are sick, you’re coming home sick.” She says she doesn’t get much time off to recuperate. “A day or two, because we don’t have very much [sick] days; we just have ten days. When I have my days off, I’m not feeling good.” In other words, sometimes she comes to work with just as many germs as the patients.

Hospital Support Work: Important Jobs for Health Care Quality Hospital support workers may be overlooked and undervalued, but they understand the importance of their work. These workers know, from their daily experiences, what many others simply overlook: they complete tasks that are important for the patients’ well-being. “I work in the day-care surgery area, and if I don’t get that bed made the whole line will stop,” says Freda Bansal. “A kid goes in for a surgery, and when the kid comes back, they really need the bed. If I don’t clean the bed, the kid is still stuck in the waiting area.”61

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For some, this sense of value and accomplishment trumps the hazards and indignities of the work. Renata Patel puts it this way: “I love my job. I feel like [it’s] my home. And I want it nice and clean and tidy. And this place should be clean all the time. This is a hospital, and we need clean everything. Don’t try to just go on top and no clean under the bed and lots of dust, no, no. Just clean always. I love that. My supervisors and managers aren’t good, but I love my job.” Support workers believe that helping patients recover is a part of their jobs. “I feel that the people I clean the beds for are my loved ones,” says Daisy Utak, housekeeper. “Some of them cannot speak for themselves anymore, so I think that they deserve something good, even from a housekeeper like me, because they might not be there for a long time anymore.” Ernesto Cortez, dietary aide, says, “I have to say I like my job because I feel that I do something to help people even if it’s only serving food to sick people. I guess that’s the way I am. I like to help people.” Kerry Lyons, another dietary aide, said she feels her job is worthwhile because “I think I am contributing to a big job. I’m helping, I’m helping patients.” Maria Ganpule describes her sense of duty as going beyond her normal working hours. “I volunteer in the hospital when they need somebody to do the angel projects and for fund-raising for foundations. I help them after my work hours. They say, ‘Maria, we’re having this singing contest or eating contest or game contest or we need a dancing person.’ I put my name in there.” These experiences help her feel like a part of the health care team, which is a big reason why she feels “very satisfied” with her job: “Because when I do my job, people give me nice comments. Yesterday the nurse, head nurse and a care aide they were talking to each other, ‘look the floor looks so nice. How Maria left it . . . ’ Today I finished my job and the office side, they gave me a big chocolate box. I gave it to all my workers and I said, ‘Here, I got this for appreciation that I did the job.’ So I feel good doing that. People were so nice. I’m not allowed to talk, but I smile.” Support workers may feel that they’re doing important, even life-saving work, but contracting out has pushed them out of the health care system. Even though they work in a hospital alongside doctors, nurses, and patients, they work in an outsourced netherworld.

3 COMPROMISING CLEANLINESS How Outsourcing Keeps Hospital Workers from Doing Their Jobs

The more time I spent with hospital workers, the more I realized that the impacts of outsourcing went far beyond a hospital bottom line. The people cleaning the floors and preparing meals suffer at both work and home. But their stories also point to a much bigger problem, a problem that has the potential to affect the health of the entire community. Simply put: outsourcing has made hospitals less clean and more vulnerable to outbreaks of infectious pathogens. Whether they originate in the community or an ER, these pathogens pose a grave threat to patient safety once they contaminate the hospital environment. My research reveals some of troubling root causes that expose hospital staff and immunocompromised patients to dangerous pathogens. When hospital support workers lack the adequate time, resources, training, and expertise to properly do their jobs, patients are at higher risk of getting a dangerous infection.1 Many hospital cleaners are dedicated to doing a good job, but remarkable obstacles stand in their way. In some cases, the trouble boils down to a basic lack of supplies. It’s hard to clean a room well when you have to reuse dirty rags or skimp on cleaning solution. These shortages are compounded by a shortfall of workers; in addition to saving money by cutting wages, many contractors cut the number of staff, too. Overall, outsourcing creates the wrong incentives when it comes to ensuring a sanitized environment. In his “Report on Infection Control in the Vancouver Island Health Authority: A Focus on Action,” Dr. Robert Stanwick, chief medical officer of the Vancouver Island Health Authority, points to the perverse incentives created by the profit motive, the primary reason for understaffing by private contractors. Stanwick 36

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notes that for-profit contractors frequently face a conflict of interest between profit and hygiene.2 For example, contractors originally planned to compensate for staffing shortages by creating a “SWAT team” of cleaners to help with busy areas and outbreaks, but that SWAT team was never created.3 It is important to remember that hospitals don’t need to just look clean; they have to be properly disinfected, which is why adequate staffing levels are so important.4 Research suggests that staffing accounts for over 90 percent of the cost of cleaning health care facilities. Therefore, it’s not surprising that direct cuts to support services in health care generally result in reduced staffing levels and dwindling benefits for the workers who remain. Understaffing is a pernicious problem affecting many lower-tier service-sector workers.5 In hospitals, workers who are expected to finish the jobs of two or three people inevitably take dangerous shortcuts or skip crucial steps necessary for proper disinfection. Many get so overwhelmed and stressed that they quit their jobs before they really have a chance to learn the trade. And no matter how swamped the workers get—no matter how many people call in sick, no matter how many more tasks need to be completed during an outbreak—the contractor is reluctant to call in reinforcements. Why? It is challenging to maintain a properly trained pool of surplus casual on-call workers who can fill in at a moment’s notice to disinfect operating theaters or dialysis units. Most people with that kind of training want regular hours and do not aspire to sit by the phone every morning hoping to get a call offering them a shift. But, most important, calling in extra workers would mean extra paychecks at a definite cost to the profit margin.

No New Mops or Uniforms: Rising Profits, Scarce Supplies Companies in charge of cleaning hospitals have found another way to cut cost— skimping on supplies. When I interviewed workers, I heard over and over again that they lacked the tools to do their jobs properly.6 Perhaps I shouldn’t have been surprised. One previous study found that outsourced housekeepers at a hospital in Vancouver received only one pair of disposable gloves per shift.7 This may seem like shocking negligence in light of the risks of transmitting infectious pathogens around the hospital, but cutting back on supplies makes good sense for the cleaning company. After all, the contracting company doesn’t have to pay to control an outbreak of C. difficile caused by inadequate cleaning; in fact, it might get a bonus if an intensive cleaning is required. The contractors only have to supply the workers and the supplies—and in each case, the fewer, the cheaper.8

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The consequences of inadequate supplies and understaffing are borne by patients and the health care system. The costs ultimately land on someone other than the contractors. The lack of incentives can be paralyzing because it takes a real commitment to keep a hospital clean. Properly disinfecting a hospital requires adequate supplies, enough time, and appropriately targeted cleaning solutions.9 A Chicago Tribune article goes so far to claim that 75 percent of hospital-acquired infections could be prevented through cleaner “facilities, instruments, and hands.”10 The article quotes Dr. Barry Farr, a leading infection-control expert and president of the Society for Healthcare Epidemiology of America, as saying, “The number of people needlessly killed by hospital infections is unbelievable, but the public doesn’t know anything about it. For years, we’ve just been quietly bundling the bodies of patients off to the morgue while infection rates get higher and higher.” Unfortunately, cleaning contractors have very little motivation to promote cleanliness. As long as the contractors meet the minimal standards set by inspection teams, they continue to hold on to their contracts. When they fail, at worst, they may lose their contract, leaving the hospital and health care system to literally clean up their mess. Even after outbreaks, failed inspections, and other mistakes, private contractors usually get away a slap on the wrist. The lack of resources extends to incredibly basic supplies required for properly cleaning and disinfecting a hospital. You would think that housekeepers would have everything they need to clean toilets that are shared by multiple patients. But Renata Patel, housekeeper, reports that is not always the case at Cumberland Hospital. “They didn’t even give us supplies,” she says. “I want a blue toilet bowl cleaner, and I asked last Saturday. And they [the managers] say, ‘No, we don’t have.’ The washrooms stink.” She says that all she would need to clean the bathrooms properly is a fresh supply of 7-10, a bathroom cleanser. “We tell [them], but they didn’t want to order. I tell my manager. ‘Why you don’t order the 7-10? We need 7-10 because the washroom is so stinky!’ He didn’t listen. He didn’t care.” How far will contractors go to save money? Patel says that she’s down to one uniform, but her company won’t give her a new one. She received three uniforms when she started her job more than four years ago. From the contractor’s perspective, that’s evidently more than enough. From an infection-control perspective, that means she is potentially transferring pathogens around the hospital throughout her shift. Contaminated uniforms or scrubs easily help spread germs from one room to the next. One study of a hospital in Israel, published in the September 2011 issue of the American Journal of Infection Control, found that 60 percent of uniforms worn by doctors and nurses tested positive for potentially dangerous bacteria.11

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Naturally, Patel has to wash the one remaining uniform after every shift so it’s ready for the next day. Some workers have had to get creative to make up for the lack of uniforms. “A lot of ladies are wearing hospital scrubs,” Patel says. “It’s technically against hospital rules, but it beats the alternative.” Freda Bansal, a housekeeper who also works at Cumberland hospital, is one of the workers who has resorted to hospital scrubs. She received four new uniforms when she started—but that was six years ago. “We even wanted to get that into our contract that they have to provide us with a new uniform each year,” she says. “But we could not get that. They did not agree to that. Our job is very dusty and dirty. I don’t want to wear the same thing every day but they don’t want to give us uniforms. Now 50 percent of the staff have already started wearing hospital’s [scrubs].” When asked how they get these hospital scrubs, Bansal says, “The hospital staff they just leave it in stuff, everywhere, so we just take it.” It goes on. Juanita Romero, a fifty-five-year-old Filipina housekeeper, says she often doesn’t have paper towels to wash her hands after picking up garbage or dirty linen. These heavy linen bags include soiled diapers, used bedsheets, and pillowcases that are potentially contaminated with pathogens. Paulo Rozero, another housekeeper, says she doesn’t have what she needs to properly disinfect and clean floors: “Working with one mop all day long, getting from one room to the next, including isolation rooms. What do you expect to happen? All those things are really upsetting, especially for us. You have to adopt the attitude of ‘I don’t care,’ like the other people do. . . . And that’s hard.” If a housekeeper uses a the same mop all day—even in isolation rooms reserved for patients with contagious infections—they could actually be spreading germs around the hospital rather than cleaning the floors.12 Juan Laguatan, housekeeper, explains that he often has to raid other units to get what he needs. “Their job is to give us the materials [supplies]. All I have to do is clean, but most of the time, they don’t want to look for the materials. The basic needs: rags, mops, something vacuum cleaner bags. So you spend a lot of time going for that and the hard part of that is they expect you to clean 100 percent of the area.” Inevitably, shortfalls of supplies lead to skipped steps and unfinished work tasks.13 Ruby Das, housekeeper, explains it as, “We don’t have cleaning stuff, like mop, or dust mop. We don’t have these things some mornings, nothing. Really! It’s true. We go there, oh, no head for the dust mop today. How can I clean without a head for the dust mop? Now tell me.” Luisa Talong, a fifty-eight-year-old Filipina housekeeper, laments how the thoroughness and frequency of their cleaning has decreased since outsourcing: You can’t clean everything. . . . What’s happening is, you just go there and dust mop. Pick up the garbage. Wipe little thing, go to the next. You

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can’t really . . . scrub your floor or wash the floor. . . . We just spot wash there, when we feel that it’s sticky, we just run it with the mops and that’s about it. Before we were privatized, we can clean the rooms. That’s why the patient was so happy because every day we clean, we wash and dust mop. We clean the washroom every day. We brush them every day. Today, only once a week, we have to brush the toilet. That’s what the management was telling us. They want to save those disinfectant cleann-shine. . . . Now they said, “No, you just have to clean once a week.”

Understaffed and Overworked Pamela Castles, hospital housekeeper, says she knows a sixty-two-year-old housekeeper at her hospital who is responsible for thirty-five rooms—a tall order for even the young and energetic. Castles herself is responsible for twenty-six rooms, not including isolation rooms and the hallways. With too many rooms to clean and too little time, she says, “it’s rushing. It’s running from room to room, so the level of service is not what it should be. It’s poor.” Linda Appleton, a fifty-year-old Canadian housekeeper at Lexington Hill Hospital, is responsible for the disinfecting and cleaning of the entire operating wing of the hospital with only three other cleaners, who arrive in staggered shifts over a twenty-four-hour period. She explains the challenge: The operating area’s a very big area. . . .You have a sterile core that we have to clean ’cause it’s sterilization, it has to be maintained. Then we have a men’s locker room, a boot room where you put your scrubs on to go into the operating room. Then we have an anesthetic office for the doctors. We have a lab. We have the manager’s office. Then we have pre-op. That’s where the patients come before the operation which is a huge area. . . . Then you have ten operating rooms and then we have a dirty utility room, a clean utility room with a service office. And we have PACU [post-anesthesia care unit] which is where the patient goes after the operating. We have an anesthetic office, perfusion office, lounge, three lounges. And two big open heart rooms. That’s what we have to clean and maintain. No wonder, then, Appleton exclaims, “from the minute I get into work, I’m running. Run. You don’t stop. That’s just the way it is.” She describes witnessing inadequate cleaning of patient rooms, especially during rushed periods with large numbers of discharges. She’s very aware of the germs around her: “Every ward has it. . . . Every ward. I mean, when you’re starting to get it in your prenatal ward, that’s not good. . . . You’ve got patients that have VRE, MRSA, they all go down to the cafeteria. They’ll have their gown on; they’ll have their glove on. But they’re

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still touching everything. You don’t have someone behind them wiping everything as soon as they get up and leave. It’s impossible, so it’s bad. . . . We have a lot of cross-contamination.” Catherine Ellis is a forty-nine-year-old French-Canadian housekeeper who works at Oak Park Hospital, where they only get about five minutes to clean an operating room before the next patient enters: We have six O.R.’s, and we can have three come out at the same time. You’re expected to get that room done in a certain amount of time, under five minutes to clean a room, get out and get into your next room. We don’t do any moving of furniture or anything, beds or tables, or equipment, luckily, but . . . we got four rooms coming out, let’s go and get those done. If there’s two of us we can usually get it done in about three minutes. It’s not a full bed like a hospital bed. And you have wires, two or three tables, and the floor. Diana Mamaril, hospital housekeeper, is very clear; she is so rushed that she’s forced to take shortcuts. Unfortunately they are precisely the kinds of shortcuts that increase the likelihood of a patient picking up an infection from the previous occupant of a room: When there are too many patients the only thing that you can do is pick up the garbage, do a little wiping and dusting here and that is it. Just the essential, not the extra like working thoroughly from up and down, side to side. You don’t have that much time. . . . We have to go into the exam room when the patients are gone, so first thing I do is to pick up the garbage, and then I come back to sanitize just the essentials that I need to sanitize. The same with the chairs, the tables and then if linens are dirty, and then I have to change the linens and then that is it. . . . I have forty-one exam rooms. So around maybe more than altogether a hundred maybe, in a day—a hundred or more. Ask hospital workers about their experience on the job, and most will mention stress—a great deal of it. In any work situation, from offices to restaurants to hospitals, stress is the ultimate barrier to performance. Stressed-out workers simply cannot do their jobs well, a fact that can have serious consequences in the hospital. When asked what causes stress at work, Eve Nicdao, a fifty-one-year-old Filipina housekeeper, puts it succinctly: “We need more people to help us.” It’s a universal theme among contracted-out support workers: The combination of understaffing and heavy workloads makes the job much more stressful and difficult than it should be given the importance of keeping hospitals clean.

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With the low wages paid to these workers, it would be easy to assume that companies could easily afford to hire more staff if they wanted to. But remember: these are the same people who are unwilling to invest in extra rags and uniforms. In that context, a few extra minimum-wage salaries can seem like a big expenditure. The increasing incidence of hospital-acquired infections also requires more intensive and specialized “isolation” or enhanced cleaning.14 But in the real world, intensive cleaning is a rare luxury. In a recent study, researchers used an invisible ink and a portable black light to test cleaning quality at three U.S. hospitals. The study found that, although some traditional sites, such as sinks and toilet tops, were cleaned, many other high-touch objects or surfaces such as patient room and bathroom doorknobs were systematically missed in most cases.15 These findings support other research, including one study that used an adenosine triphosphate (ATP)-bioluminescence tool in four U.S. hospitals and revealed unacceptable cleaning and contamination of patient rooms.16

Looking for Help The worker shortage at hospitals is exposed every time someone calls in sick. In theory, the shifts of absent workers could be covered by temporary workers in much the same way that schools can call on substitutes to cover for ill teachers. But contractors generally don’t have a lot of on-call workers to count on, and the ones they hire generally don’t stick around. Lily Oracio, a dietary aide at Mapleview Hospital, feels that managers could easily solve the problem of understaffing by guaranteeing a certain number of minimum hours to on-call workers. “They hire employees, but of course if you [contractors] don’t guarantee them hours, they will look for another job,” she says. “So every time you [contractors] call them when you need something, they’re not available. But if they guarantee them that no matter what you [employees] have three full-time days in one week, they’ll stay.” Maintaining this kind of surplus pool of support workers would be expensive for contractors, so instead they wing it, often with only the workers who show up for their shift. Cheryl Manopol, a forty-four-year-old Filipina dietary aide, explains, “They could create more jobs or give the part-time people longer hours, but they wouldn’t do it. I think they are trying to save on money and we girls are talking among ourselves that probably the reason they wouldn’t call the casuals when somebody is absent is because they don’t really want to pay somebody. They just want us to finish the job. ‘Two people short? Everybody help out.’ ” But covering the jobs of those two missing workers means everyone’s assigned tasks get even less attention. Stuff gets missed—important stuff. A lack of regular cleaning

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erodes hospital hygiene both visually and, more important, microbially, so that reservoirs of pathogens take root on high-touch areas and in grubby corners. Diana Mamaril, who works at Broadway Hospital, says that short staffing makes an already tough job that much worse. She explains that cleaners have to “rush from our area to go to the other area and help each other just to finish the job.” Renata Patel reports that a fully staffed cleaning crew has become a real luxury: “Last month, Sunday, seven ladies short. Seven, sometimes eight workers short. They didn’t call anybody. . . . workers were waiting and on the phone, but they didn’t call. . . . The sick call in sick, and the supervisors didn’t replace. They didn’t call the on-call ladies, [Instead] they pool all the ladies. One person will do a three-people job.” Many of the workers fondly remember days when there was enough staff to get the job done. The days before outsourcing, that is. “I’ve seen our staff go down,” says Sam King, a forty-eight-year-old cook. “There used to be thirty-one of us, and now we’re down to, I think it’s twenty-five. We find ourselves trying to cover for each other most of the time.” The understaffing makes the job more physically challenging for King. “It’s getting harder. I do a lot, I really do. It would be a lot better if we had one more person on at night.” These statistics mirror the broader trends in the ratio of health care staff per patient; as hospitals get busier, more crowded, and have higher turnover, they have been cutting back and disinvesting in support staff.17 Bonnie Kruja, a fifty-nine-year-old housekeeper from Fiji, says “The work I’m doing now is like two people’s job. . . . I’m working almost like a health slave.” With fewer workers on shift, they are asked to complete more and more tasks. As Ruby Das attests, supervisors add new tasks to an already heavy workload: “Always they ask more and more. And always they say, ‘It’s in the contract, it’s in contract.’ We didn’t make the bed in past four years, and now, two weeks ago, the supervisor came and said now we have to make the beds. Always they say something, they ask more and more. And we just do it, because if you can’t do it, go home! [laughs]. No job for you.” The workload varies by the job, the ward, the hospital, and even by the day. The usual fast pace of the hospital is often punctuated by crisis periods, including the occasional outbreak. Yet many support workers feel like the crisis mode never stops. Over half of the support workers interviewed say they are “often” or “always” too rushed to work safely, and an additional 24 percent say they are “sometimes” too rushed to work safely. The jobs can get especially hectic after an infectious outbreak. Erika Koch, housekeeper, says she and two co-workers were asked to thoroughly clean hospital beds after a bacterial outbreak. “You know how many beds? In one day, one time: twenty-four beds. We have to wash them, and we have to put sheets on them. It was just three people. Plus our [regular]

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workload. This other girl was crying. She said she’s gonna quit; [it was] just too much. My back was hurting me, honestly. So I’m not gonna do this again.” Frederico Hilaga, cook, says the heavy workload is exhausting him. “We have a lot of work to do. When I was working with the Health Authority [preoutsourcing], we had more people to do the work. Now, everything is compressed. If I work from 10 a.m. to 6 p.m., I am very tired. I can’t do anything anymore. I used to go for a movie or something and now I can’t. My body is telling me that I’m tired.” In addition to being asked to do more work, Hilaga is also required to complete a greater variety of tasks post-outsourcing, including tasks that should have been finished by other workers: “With the work I am doing now, I am responsible for ordering and inventory. Aside from that you still have to do actual cooking, prepare the menus, recipes, serve it. Before, when I was working as a chef at Alderwood Hospital, cooking was it, you’re done. Now it’s different. When you’re finishing cooking, you still have to do serving, when in fact that that should not be my job. Everything is multitasking. . . . The cashier now he has to do salads.” Many support workers report being required to cover more roles, multitask, and do more with less.

The Consequences of Rushing Mark Pilande, a housekeeper at Broadway Hospital, says he rarely has enough time to do a thorough job. “They just push you to do it so you have to cut corners to do the job and then it comes back to [haunt] you.” Under pressure, a housekeeper might decide to skip dusting before mopping. But if a floor isn’t dusted first, mopping just moves the dirt—and possibly the pathogens, including C. difficile spores—around the hospital. This obviously increases the chance of an outbreak, and it has practically become the standard operating procedure for many cleaners after contracting out. Workers are frustrated at the constant pressure to cut corners to complete the overwhelming number of tasks. Daisy Utak, housekeeper, says, “there is so much to do, for just [so] little time.” As a result, she skips cleaning “corners and some beds. They are not really being cleaned properly. I feel bad because I cannot do more, as much as I want to.” Skipping beds is a major threat to patients safety; Stephanie Dancer, microbiologist, has shown that disinfecting the rails of patient beds is a critical step for preventing the spread of infection.18 Housekeepers know that, while they’re cleaning a room, there’s almost always a patient waiting to fill it. (Often, that patient is on a stretcher in the hallway.) Renata Patel describes cutting corners as she rushes from one extensive room cleaning to another: “Because lots of [patients] discharge, I can’t finish dusting

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all the stuff. They want us to wipe the walls and everything, and I don’t have time for that. Sometimes they want us to wipe the chairs. . . . But I don’t have time. As soon as I go and start to do that and wipe the chairs, they call a bed and I have to leave and run there. They say ‘Renata, can you please do this room, and clean that bed?’ and the person is waiting there.” All this rushing has consequences for the quality of her work. “My supervisors come in, and they say, ‘Oh, Renata, you didn’t do this, see how dirty [it is] here, the dust there!’ What can I do?” My conversations with outsourced cleaners suggest that some wings and some hospitals push the stress to extremes. The ER poses a special challenge, and not just because of all of the blood and germs. Vincent Stevens, a nephrologist at a Vancouver hospital, reports that when the emergency room gets crowded, “Right now they will cohort people with antibiotic resistant organisms with people who are not yet infected based upon their over capacity protocols. These people will be sharing a toilet in the four-bedroom and if you really wanted to ensure spread of infection, this is exactly the way you would do it.” Pre-outsourcing, three support workers used to clean the ER in the hospital where Patel works. Today, the ER is cleaned by two shift workers. As Patel relates, not all the workers are up to the job, and the ER—arguably the most important part of the hospital—is often a real mess: “When I go in the morning, everything is dirty. Those washrooms stink and everything. . . . And they don’t care. The supervisors, they don’t care. They don’t care, nothing. And they should check, right? They should check.” Patel continues, “Altogether we have maybe forty-two beds plus chairs. They sit down people on the chairs and lots of extra persons there. They put beds in the hallway. We can’t count that you know? Sometimes I go in at 7 o’clock, and I’m like, oh my goodness, all the hallway is full of patients in the beds. . . . That place is so busy. And never, we never get help. We never stop, never stop there. There should be three people [cleaning] at that place; we’re only two.” “Some days we are so desperate for help,” says Freda Bansal. “Today they just bombarded me with so much work and I asked them for help and no help came. They are always short up there. They are always asking people to do overtime, but I can’t pull overtime. It’s such a heavy work; I cannot do a double shift. People are always calling in sick, someone is always hurt.” Understaffing sets up support workers to fail. Of the workers interviewed, 60 percent reported that they do not have enough time to finish their assigned tasks. Amita Pamintuan, a housekeeper at Bayside Memorial Hospital, says, “sometimes when they pull you out from the one area to go discharge in the other area, you will not be able to finish your job in that area.” When asked how often in the last month she felt like she was too rushed to work safely, she replies “always.” She says, “When I was assigned in maternity, you have to rush and rush because there is a patient there waiting to be born. So you have to clean the room right

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away. Sometimes you can’t even mop the floor, and they say ‘Oh, she’s coming, she’s coming.’ ” Like other cleaners, Pamintuan has learned to dread discharges. Whenever a patient leaves a room, the pressure and the stress mount. “You have to do it fast especially in the CCU [critical care unit],” she says. “Sometimes I’m stressed because my supervisor [says], ‘You have to finish that. You have to finish your rotate.’ In my mind [I think], ‘Oh my god, I have to do this, I have to do that.’ ” Unfinished work inevitably gets left for the next shift, creating a vicious cycle that keeps everybody running behind. Peter Wu, a housekeeper at Mapleview Hospital, explains that “if the night shift left work for you in the morning, there’s no time at all.” He continues, “We have to make sure everything is clean, because of infections. I spend an hour doing their job and it makes my job delayed. I have to rush, rush . . . ”

Paying the Price The hospital is often a busy, high-stress work environment and that extends right down to the cleaners and food service workers. Seventy-four percent of support workers interviewed say that they feel that their job negatively affects their physical health, and 70 percent report that it negatively affects their emotional or spiritual health. Daisy Utak says her extra work led directly to a health scare: A couple of months ago, [my supervisor] was telling me to mop the entire floor in front of nurse’s station. Since the hallway person is on vacation, there was nobody there to do his job. So I talked to my supervisor, and he told me to mop the whole floor. I told him that mopping is not included in my job. He told me to, “Just do it.” When it was all done, and I also did the dining room in front of the nurses’ station. At that time when I finished everything clean, and I felt really upset, and I wasn’t feeling good working that day. I had a terrible headache and I went to the nurse and asked them if they can take my blood pressure because I had been having a headache. And my blood pressure was really high. They had to send me to the emergency. A shocking 63 percent of the outsourced support workers interviewed report that they have been injured or sickened in their job. Housekeepers in hospitals and long-term-care facilities have injury rates over four times higher than the average industrial worker, according to Marjorie Griffin Cohen, political scientist. They also have high rates of infection, especially from hepatitis B, salmonellosis, and scabies.19

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Minor injuries and repetitive strain reduce the capacity of some hospital support workers to properly complete their job. “It’s every day the same story. We are always rushing,” says Freda Bansal. “See I banged my hand so badly last week, last Monday. It’s been two weeks, and it’s still not healing. And this hand also because I was just quickly mopping, and then I hit my hand on the door. You are always rushing. Otherwise you can never get finished.” When these workers are rushed, on-the-job injuries become a real hazard. Ernesto Cortez, a forty-five-year-old dietary aide at Broadway Hospital, says he often rushes past the point of safety: “It could be unsafe yes, because we have a time to start and to finish serving. You have to rush, and it sometimes could be unsafe because you’re rushing and sometime may fall, anything on the floor, and you might fall. You might slip and fall. When we go to work sometimes it’s over-crowded, sometimes there are beds all over the place, or beds or any equipment, it can be very challenging to move around.” Cortez says he has hurt his back twice on the job; in both cases, he says he was too rushed to pay attention to proper lifting technique. Workers employed more than five hours in a row are required by law to get a meal break. Their collective agreement also includes provisions for additional breaks during the day. In reality, the workers report often skipping their breaks to catch up on their overwhelming checklist of tasks to complete. Maria Ganpule, a housekeeper at Coast Mountains Hospital, has been injured four times on the job. One time, she was badly cut and needed to get emergency stitches. “I had a discharge [room], and then I had to go and finish my complete clean,” she says. “I was rushing, and I pulled my housekeeping door, and I got cut and I needed the stitches. . . . the blood was just pouring.” Despite all the blood, Ganpule’s supervisor dismissed her injury: He said “Oh nothing’s wrong.” And then the doctor said, “No, she needed three stitches.” So I got the three stitches and my painkillers. Then the supervisor said, “What you going to do?” I said, “Well I’m not feeling good now, I took the pain killer I’m going to go home.” He said, “No! You’re not going home. You going to go now and finish the job because it’s too late now. I cannot replace anybody.” So I went and started vacuuming, and the stitch broke again. So I told the nurse, and she said, “You leave everything and go! We’ll support you!” So they gave me a note that I cannot work for three days and I have to keep my fingers dry. In addition to being cut several times on the job, Ganpule has also had her wrist injured by a toilet seat and had her fingers pinched in a collapsing bed frame. After she returned to work with a bandaged finger, her manager assigned her a “one-handed” job to clean a stack of wheelchairs on a freezing hospital loading dock during a snowstorm.

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“Everybody was laughing,” she recalls. “They said, ‘Why are they doing this to you?’ I said, ‘This is my punishment for getting injured.’ I have been through so much with this company.” In the end, she won a settlement for pain and suffering.

Taking Their Toll: The Heavy Physical Demands of Hospital Support Jobs Even prior to outsourcing, hospital support jobs were more challenging and difficult than most people imagine. After contracting out, things have only gotten worse. Asked to rate her job on a scale of 1 to 7 in terms of physical demands Lucy Cusito, a dietary aide at Forest Park Hospital, gave it a 7. “We do have heavy lifting, like boxes of cans. You’re always on the go, always pulling and pushing heavy stuff.” Nearly all support workers rate their jobs as very physically challenging, with 75 percent rating it a 6 or a 7. Francine Rankin, a fifty-three-year-old Irish-Canadian housekeeper, describes some of the challenges: “The garbage often is overloaded. There’s the diaper bags which are really big and they’ll often weigh 30-plus [kilograms]. And the bags of the dishwasher, again, really big bags and they’ll weigh 30-plus [kilograms]. And that’s how I hurt myself was lifting one of these heavy bags. We have to lift it up to here [shoulder height] to get them into the compactor. . . . It’s really, really, really heavy.” In a typical shift, “On Saturdays, I probably lift a hundred bags of garbage.” She explains, “I ripped a tendon lifting a heavy bag.” In another workplace injury, “my rib was pulled off my rib cage and it was floating around.” Older workers aren’t the only ones worn out by their work. Diana Mamaril, a thirty-four-year-old housekeeper at Broadway Hospital, also rates her job as a 7. “The garbage. It’s too heavy. I can’t really estimate the weight but if you have an idea of what 35” × 50” garbage bag [weighs]—it’s full and sometimes it’s around seven or six in a day. Sometimes I ask the help of my male co-worker, especially now that I am pregnant. It is very hard.” Gaya Johl, dietary aide, injured her shoulder so badly putting away a 50-lb bag of cereal that she had to take eleven months off to recover. She was doing a job she was never trained to do. Talking to workers who had been injured on the job, I heard again and again that safety-training programs fell far short. Nobody ever taught Eve Nicdao how to use a floor-cleaning machine, an oversight that she says lead directly to her smashed finger. “My supervisor then, [the] awful one, he encouraged me to go back to work. I went back to work although my stitches weren’t finished yet, and I could hardly use my hand.” Nicdao also says that she spent years battling an illness on the job. “I was coughing so bad, fever, and it was difficult to breathe sometimes,” she says, “My

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doctor was saying it was bronchitis. I was very weak and was only able to recover after four years. I think it was infection and chemicals.”

Repetitive Stress Injuries It takes a lot of repetitive motions to clean a hospital or serve food to hundreds of patients. It’s practically a recipe for overuse injuries. Lily Oracio rates her job a 7 on a scale of 1 to 7 in terms of heavy physical demands because “When you’re serving straight for two hours, and when you’re delivering trays, that’s continuous. It’s hard!” Juan Laguatan wonders how all the strain and other on-the-job hazards will affect his future: “What [will] you be in five years? You exposed to VREs and exposed to the MRSA most of the time, so what [are] you going to be in five years? You have to think of that. Seven hours every day running to and fro, lifting heavy objects about, so you feel some pain definitely. For how long [can] you sustain that kind of pain? You could be part of Paralympics organization sooner or later.” Kerry Lyons, dietary aide, complains that the strains and danger posed by her job seem to overshadow the paycheck: You have the dirty plates, you have to separate the spoons, the cutlery, and then everything, cups from bowls and everything. You got the dirtiest job. That’s the dirtiest job, stripping. The bacteria are all over the place. So it is really, really hard. . . . You’re paying me $10 dollars [per hour], it’s not worth it, it’s not really worth it. . . . Of course I need money, I have to earn money, but didn’t realize I have to carry a big bin full of garbage down to the tunnel. . . . It’s not worth it if I break my back, it’s not worth it. [Even] $17 dollars [per hour], no. Definitely it’s not worth it. Exhausted, devalued, and overworked. Is it any wonder they aren’t able to fulfill the high standards of precaution and hospital hygiene required for preventing infection?

Profit above All: Denying Injuries, Fighting Claims Some outsourced hospital support workers claim that their supervisors and managers try to cover up or minimize injuries to prevent them from receiving appropriate compensation from the government. There are two ways for companies to lower costs of worker injuries. The first is to take the high road by providing training, active health and safety committees, and safe workplaces. The

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second—the low road—is to prevent injured workers from successfully making workers’ compensation claims (which then result in increased premiums the contractor must pay to the government). Post-outsourcing, the contractors have clearly opted against taking the high road. As Renata Patel relates, “lots of ladies here [are injured] in the workplace, but they didn’t get WCB [workers’ compensation benefits]. The workload is heavy, lifting garbage. Lots! They [management] didn’t care. They didn’t give help. No.” Patel also says that the managers ignored doctors’ orders. “When some ladies come back from the injury and WCB, and doctors [recommend] light duty, they didn’t care. They just send anywhere. Anywhere they want they send you. And do this, do this, do this, do this. They didn’t give light duty.” In 2007, Patel broke her wrist when a nurse accidentally hit her with a door. After this injury, she says her manager tried to block her application for workers’ compensation benefits on the grounds that she should be able to complete “light duty” jobs even with her hand injury. After much wrangling, she was finally given workers’ comp benefits two months later. This payment, however, provided little relief from an injury that rendered her dependent on family members to help her do the simplest things. “I didn’t do anything at home,” she says. “My sister came and bought groceries. For many months, I never drive, I can’t. It’s still sore there.” Hospital support workers complete physically challenging and important work every shift. Cutbacks and understaffing together have made this work even more difficult, forcing workers to take shortcuts that leave patients more vulnerable to infections. Workers put their own health and well-being on the line every shift—but they aren’t the only ones in peril.

4 UNTRAINED WORKERS, UNFIT MANAGERS

The entire air transit system had been privatized, deregulated and downsized, with the vast majority of airport security work performed by underpaid, poorly trained, non-union contractors. . . . On September 10, as long as flights were cheap and plentiful, none of that seemed to matter. But on September 12, putting $6-an-hour contract workers in charge of airport security seemed reckless. —Naomi Klein, The Shock Doctrine1

For all their hard work, cleaners and cooks know they are not doing a good job. In fact, they are surprisingly open about the kinds of shortcuts they feel forced to make.2 Juan Laguatan, housekeeper, says, “It’s screwed, of course. Quality of service? Only just on paper. But in reality it is not. Just like maybe on bulletin boards and elevator: ‘We are at your service.’ But in reality it is not.” The risks to patients of cutting corners and improper cleaning are high because contaminated surfaces can serve as a vector for the spread of infection. Veronica Sendal, an epidemiologist and hospital consultant on infection control, explains the stakes: “if I have one patient who’s got C. diff and then another patient puts their hands on a contaminated bedpan or a contaminated toilet seat and then don’t wash their hands after—there is a potential risk there. The various mechanisms of transmission are very complex— and anything can serve as a reservoir if mishandled for another patient, so we have to be extremely vigilant.” We have already seen the consequences of rushed workers and unrealistic demands. But outsourcing has also eroded work quality in other, less obvious ways. In simple terms, outsourced support workers are simply no longer prepared to get the job done. And neither are their supervisors.

Nanaimo General Hospital: Unprepared for Outbreaks All too often, it takes a disaster to expose a breakdown in a system. A 2008 outbreak of C. difficile at Nanaimo General Hospital on Vancouver Island uncovered an 51

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incredible lack of preparedness by workers and managers throughout the hospital. After the superbug was first discovered, workers were told to scrub all surfaces with bleach. Unfortunately, as reported in the Victoria Times Colonist, the contract cleaners never managed to clean the ER or the digital imaging suites because these areas were too crowded. To make matters worse, it was later discovered that the cleaners were using a bleach solution that was about one hundred times too dilute to effectively kill the bacteria.3 For several months, perhaps even longer, the housekeepers were trying to fight one of the world’s most dangerous germs with a solution only slightly more powerful than tap water. In a detailed audit, the British Columbia Center for Disease Control (BCCDC) concluded that errors made by outsourced hospital cleaners contributed to the outbreak that sickened nearly a hundred patients and killed at least five. The audit notes that “there is an ongoing perception that there are insufficient housekeeping staff to clean the facility to the level required in the contract, particularly overnight and on weekends.”4 Among many causes, including poor hospital design, incomplete environmental disinfection allowed parts of the hospital to become reservoirs for pathogens and infecting patients.5 The report mentions one notable way that germs can spread from one patient to another—aerosolized feces. It seems that the new machines designed to clean bedpans had a tendency to splash nurses in the face. Not surprisingly, the report found that regular blasts of feces lead to “a loss of confidence in the machines by nursing staff. It is highly likely issues with inappropriate cleaning of bedpans have been a major factor in the spread of CDI [C. difficile infection] in this outbreak.”6 Other, less memorable factors that contributed to the outbreak included overcrowding, lack of isolation rooms, and poor design factors that forced several patients to share rooms and washroom facilities. The outbreak at Nanaimo General Hospital serves as a perfect illustration of the dangers of outsourcing cleaning. Not only were workers unprepared to respond to the crisis, they were unable to prevent it from igniting in the first place. And the consequences were grave. Patients continued to become ill and die from infections until C. difficile was finally successfully eradicated from the hospital, months after the initial outbreak. Despite audits and some reforms, the same hospital also experienced two other outbreaks of C. difficile and norovirus only two years later, in spring and summer 2010.7 Without addressing outsourcing, one of the root causes of such outbreaks remains a threat.

“Bodily Fluids of All Descriptions” Long before the outbreak at Nanaimo General, there was ample evidence that the outsourcing of support jobs was putting hospital patients at risk as a result of

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environmental hygiene issues. A 2004 report presents the findings from a survey of forty-one ER department staff at St. Paul’s Hospital in downtown Vancouver. It finds that “nurses and other care providers in the Vancouver Coastal Health region are alarmed by deteriorating standards in cleanliness and by communication difficulties with cleaning contractors. In particular, hospital staff are deeply worried that infection control practices are slipping.”8 For example, 86 percent of the health care workers surveyed felt that cleaning quality had declined since outsourcing, and another 63 percent felt that cleaners were not properly following infection control protocols.9 This report describes some incredible lapses in hygiene, including: • “No cleaning of monitor cables; no cleaning of IV poles; no cleaning of stretchers; no cleaning of window sills or above curtain rods (acute beds); no cleaning of stairwells.” • “Old feces on curtains for several days. Bedsides and bedside tables sticky with juice, again for days.” • “Leukemia patient’s rooms not mopped, bathrooms not done, garbages not emptied.” • “Body fluids of all description on walls, on stretcher railings, on curtains. These include dried blood and sputum.”10 • “Blood splashes remained on wall in trauma unit [for] three weeks.”11 As noted in the report, hospital staff had many complaints about post-outsourcing cleanliness, too. “The staff washrooms are disgusting. . . . I’ve worked in this hospital for fourteen years and it’s the worst I’ve ever seen,”12 said one disgruntled hospital staff member. Other comments included “The water in the mop bucket is black and doesn’t look like it has ever been changed.” And, damningly: “Housekeepers do not seem to change cloths. One cloth is used for everything. I do not see greater effort being taken when there is an MRSA/TB risk.”13 Many hospital staff felt the new contract cleaners simply did not know what they were doing. One said, “the contracted-out staff [show] little or no initiative in their jobs. There is either a language barrier or the training they receive is totally inadequate.”14 The report noted several obvious gaffes by cleaners, including not wearing masks, not washing hands, and wearing isolation gowns backward. Nurses and other health care professionals could no longer directly request services from the support staff; they instead had to make requests to a centralized call center. Unfortunately, these telephone requests were often not fulfilled. As a result, the staff reported delays in the cleaning of important equipment, such as stretchers, which in turn led to patient backups in the emergency department.15 Others complained that the cleaners were violating patient confidentiality and

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disrupting nurses by getting in their way while completing tasks such as delivering medication carts.16 But they didn’t blame the workers entirely. As one respondent noted, “The housekeepers are so overworked [and] understaffed.” While things have improved somewhat in the years since, infection-control professionals and physicians who work in these hospitals describe serious ongoing concerns about inadequate cleaning and improper protective measures. Personally, when my mother-in-law was in a palliative care bed at a Vancouver-area hospital, my spouse noted that the “full clean” listed on the sheet next to her comprised a quick wipe-down of the bed rails and wires with a few rags—one of which fell and the floor, and was picked up and used anyway. The whole scene did not exactly fill us with confidence.

No Experience Required Why did outsourcing result in such a decline in work quality? The decision to outsource all hospital support jobs in Vancouver instantly created thousands of job openings. When many of the previous in-house support workers decided not to reapply for the their old positions—at dramatically reduced wages and benefits—the private corporations who won the contracts initially relied heavily on job fairs to recruit workers. They conducted brief assembly-line interviews, and their selection criteria for hiring were clearly limited. For example, contractors certainly did not require applicants to have had any prior health care training or experience, as used to be the case prior to outsourcing. Basic English fluency (in some cases, extremely basic) and a willingness to show up for work appeared to be the only qualifications required of applicants. Seventy-one percent of support workers interviewed say that their job was easy to get. Many literally landed their positions after the five-minute job fair interview. Some report they weren’t even aware that they would be cleaning hospital rooms and not hotel rooms until they arrived for their first day of work. Perhaps expecting the Hilton instead of a hospital, many hospital workers quit after only a short time on the job. Faced with high turnover rates, cleaning companies continue to keep an extremely low bar when hiring new workers. Most new hires prior to outsourcing had completed a Building Service Worker certificate at a local college or a similar program.17 Now there’s no guarantee that they know how to hold a mop, much less how to complete the proper precaution and disinfecting procedures for MRSA, C. difficile, VRE, E. coli, and norovirus. The decision to contract out resulted in an immediate loss of human capital in the form of the many employees with years of experience. According to Robert Stanwick, the chief medical officer of the Vancouver Island Health Authority,

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some contractors were unable to find workers to take these jobs because of the low wages, exacerbating understaffing. “Unfortunately, . . . the contractor has had difficulty in achieving a full complement of housekeepers at the $10.50 wage initially being offered.”18 He continues: A major issue surrounds training and retention of staff. Unfortunately housekeeping positions are not viewed as a career path. . . . The current cohort of housekeepers experiences an extremely high turnover rate, upwards of 50% for some months. It seemingly was only after the hourly rate wage rose to $13.00 per hour that the high turnover rate showed some improvement. This significant turnover is in contrast to that observed for the unionized employees who were terminated as part of the contracting out process. Those individuals constituted a fairly stable workforce whose numbers included many long serving staff.19 The brain drain continues to this day. Even now, many experienced workers who remain say that they are looking for better jobs. Francine Rankin, housekeeper, says, “I’m getting sick of the pressure. I’m really sick of the flu and the isolations. Every winter’s just hell.” Pamela Castles, housekeeper, admits, “I think about leaving every day.” Juan Laguatan plans to work in “another place, [at] a much more higher [wage] rate. I want to work, and earn enough to sustain my basic needs.” The companies that hold the contracts set the terms for hiring and employment of the people cleaning and serving food in their hospital. Hospital and health authority administrators no longer have control over who gets hired and fired, or what the (minimal) requirements are for those who are hired for these jobs. They also cannot mandate and enforce staffing levels, which means there is little they can do to make sure there are enough qualified and competent workers to do the job.

Short-Time Workers, Big-Time Problems Prior to outsourcing, Vancouver-area hospitals could depend on a relatively stable and experienced support workforce with basic qualification and relatively extensive training. In 2002, the average cleaner had 11.6 years of experience.20 Today’s workers average only 3.9 years.21 Today many shell-shocked workers simply walk out within their first days on the job. The ones who stick around are often vulnerable to job-ending accidents because they haven’t been trained to protect themselves. This creates a selfreinforcing cycle. With so many people leaving so quickly, the company feels even less motivated to provide adequate training. Why waste money and time on workers who are just going to quit or hurt themselves in a few days or weeks?

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Hospital support requires substantial judgment, specialized knowledge, and skills. According to the UK Department of Health, cleaning staff are “the people who can make all the difference in the basic cleanliness of the hospital environment. To do this to the best of their ability they need to be properly resourced— in terms of time, numbers and equipment—and properly trained and valued.”22 They also need to be motivated, hard working, conscientious, and efficient.

Limited Training before Beginning the Job The training that contractors provide to newly hired support workers is wholly inadequate, especially given the importance of their jobs for infection control.23 In the immediate aftermath of outsourcing, thousands of new hires received only three days of off-site training. Currently, new hires are getting by with even less. Lucy Cusito, housekeeper, says she only received one day of training from her supervisor before she started cleaning rooms on her own. In contrast, Diana Mamaril, a housekeeper hired before outsourcing, received two weeks of training, in addition to the certificate program at a local community college that she completed to become eligible to be hired. These days, contract support workers end up learning most of their tasks from other workers on the fly. Eighty-three percent surveyed say that they are responsible for training new staff, another job that, ironically, they aren’t trained to do. As years go by, they usually don’t get any additional training to deal with the new technologies, new procedures, and new threats. Over 30 percent of support workers report they regularly complete job tasks that they weren’t trained to do. With limited options, many cope by just winging it, perhaps unaware of the serious potential consequences this holds for themselves, patients, and other health care workers. Penny Bagga, a housekeeper at Cumberland Hospital, says that she spent only one of her three training days actually learning how to keep a hospital clean. And she spent that day simply working with another housekeeper. Bagga has kept the cycle going by training new recruits on her own: “I train them how to clean the bed, because sometimes when they clean the bed, they just use one rag to clean the bed—No. There is some blood or maybe some vomit or anything, you don’t want to spread all the germs in there. So I always tell them, if you are wiping [cardiac wires that are put into the heart], make sure you use [use a new rag] each wire. And then when you are doing the bed, make sure you use two rags in the top mattress and one in the bottom of them.” Bagga says many new recruits ignore her on-the-job advice. “Lots of girls, they don’t use that many rags because they do just whatever they want,” she says. “I’m doing this because who knows if my kids are going to be coming and sleeping [here], and I don’t want my kids to get sick.”

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Bagga also thinks that her company should try to recruit more educated and better-trained supervisors. “Lots of supervisors were housekeeper before,” she says. “They were ordinary people. . . . We need more educated people. Before hiring, they should check all the resumes, because it’s a hospital; it’s not a hotel. Lots of sick people are coming in there.”24 Renata Patel, housekeeper, describes problems with new hires. “They don’t have quality,” she says. “They never train. They don’t know. They never clean the bed. They made just like a regular bed. They don’t know anything.” As a result, Patel finds herself explaining the proper procedures for cleaning. Patel complains that many new hires lack the basic knowledge to even start their jobs: “Our supervisor, they didn’t train them. New people came, they give a pager and key. ‘Ok you go to this floor and this room.’ Even though they don’t know where the housekeeping room is, where the supplies are. And the housekeeping cart is empty, and they’re confused in a big hospital. They’re lost! And lots of ladies, girls, they came and they cry, and they go back home.” Even when workers do get contractor-provided training, the instruction isn’t always top-notch. Freda Bansal, housekeeper, describes learning how to use cleaning chemicals from a representative of the company that sold the chemicals. “These guys had no experience in cleaning themselves,” she says. “They were just selling chemicals to the company.” Peter Wu, housekeeper, says he was never really trained how to handle isolation rooms, the rooms that hold the most infectious patients. “The only training is basic stuff,” he says. “They only just tell you a little bit of it. When you do isolation, you gotta go inside, do everything, then you come out, you wash your hands before you come out.” Wu didn’t say so, but it is critically important for support workers cleaning isolation rooms to use proper protective clothing and dispose of materials properly. Wu says that the supervisors did not always ask the housekeepers to wash their hands, another major breach of any serious attempt to control the spread of germs in a hospital. “Once Regents took over, a few supervisors didn’t follow the regulations,” he says. “They train people, but they themselves don’t have training.” But all these extra steps take time and slow down rushed support workers, who sometimes don’t understand how hardy and dangerous these microbial and other pathogens can be. Most new workers begin as casual or on-call employees, a class of workers especially likely to get short-changed on training. They literally get dropped into a ward or wing to fill in, only to find out what they are supposed to do once they arrive. Kerry Lyons, dietary aide, relates that she was completely unprepared when Lippor first called her up to work at Mapleview Hospital: “The first time that I work for Lippor, this was my first time to see the entire Mapleview hospital.

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I don’t know where to go, where to go to emergency room, ICU room, and I have to deliver some snacks. And the thing is, I don’t know. I got lost from emergency— I went to the morgue. I was like crying, ‘Oh my God I don’t wanna work here any more because I don’t know where to go.’ ” The unplanned trip to the morgue was bad; the end of her shift was even worse. Although she had worked an extra hour and a half beyond her shift, her supervisor refused to let her put in for overtime. “My supervisor said ‘it’s not our fault that if you get lost.’ This is my first time, what do you expect?! If you showed me the way, or even helped me a bit. . . . Oh my gosh!” Lyons said that she literally received no training for the job. Someone did casually warn her about entering rooms with a pink signs on the door, a piece of advice that just left her confused. “Although I have a medical background, I never experienced that before,” she says. “So when I saw this pink note on the front of the door, I was so scared because I don’t know what’s inside.” Fortunately, a sympathetic nurse helped Lyons interpret the door codes. “If pink, you have to wear proper things to get inside so that you don’t catch the bacteria or something,” she says. “If there’s blue paper in front of the door, you can get inside without the mask, but you’re not allowed to touch anything. If you pick up the tray, you’re wearing your gloves.” Without the nurse’s clarification, Lyons could have easily contaminated herself or her supplies with dangerous germs and spread them throughout the hospital. Daisy Utak, housekeeper, received fifteen hours of training (three hours per day for five days) from Regents when she was hired over five years ago. “It was a training course because we got a certificate and a binder from Regents,” she says. She described the initial training as “all about what to expect, what to do while we are working, and I think there is some also information about supplies and health and safety. It was very, very fast. We didn’t really have the chance to go through it.” They were told to read through some of the most important material themselves. When Utak showed up for her first day of work, she was surprised to learn that she would be using different chemicals than the ones described in her training. In the absence of meaningful formal training or refresher courses, overworked and rushed co-workers fill in as mentors to new hires. These workers often feel burdened by the need to provide on-the-job training for the new employees, many of whom barely speak English. This is an unofficial part of the job. Workers don’t get any extra pay or benefits for taking the time to teach new hires. Mostly, they just get a big dose of frustration as on-the-job training of unprepared new employees adds to their already full plate for that shift. Freda Bansal explains that she trains her new housekeeping co-workers starting with day one. “I teach them from A to Z about cleaning,” she says. “I am a very

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neat freak [laughs]. After all these years of cleaning, I want everything to be done the right way and teach them the right way. How to make a bed, how to disinfect a room, and how to get the floors done. Everything.” Peter Wu also does a lot of on-the-job training. “I teach them everything: how to clean, how to mop, how to wash the floor. How to do things safely, how to do body mechanics safely. You bend your knees so you don’t hurt your back,” he says. Doria Markopoulos, dietary aide, often trains many new workers simultaneously. She says her training duties became overwhelming in the aftermath of outsourcing: It was only four or five of us who had to train eighty people. I mean you have twenty people on top of you. It was a nightmare. It was hard for us. They ask you what to do, and you have to go there and help them, do this. I mean because it’s a big hospital and it was difficult for us, at the end of the day it was, oh my god, it was very hard. Then a hundred [new] people came in, and only five or six of us have to deal with them. People are lost and don’t know what to do. We had to train everyone because of our experience. I’ve been there for fifteen years, so I knew every corner. Despite receiving only two days of training from her supervisor herself, Amita Pamintuan, housekeeper, now finds that she is the de facto trainer for newly hired workers: “When I was in maternity, I have to train them how to do discharge with the room. How to clean the tub and how to put the proper bed sheets on the bed. It’s so hard to train people. They give birth in the room and then you have to know how to clean the blood—everything. So you have to teach them how to do it properly.” Crucially, Pamintuan says she is the one who teaches new hires how to clean rooms contaminated with VRE or MRSA. “You have to wear the garb proper,” she explains. “You have to wear a gown. You have to wear mask and gloves and you are not supposed to get out. Just stay inside and pick up all the garbage and just put it near the door. Then after when you finish cleaning you remove your gowns and throw everything in the garbage.” Eve Nicdao, housekeeper, reports that new hires arrive with remarkably few skills: “Sometimes we have a lot of new workers, newly hired. They send them to work with me. It’s hard for me because they don’t know what to do. They can only pick up garbage. I have to show them how to do it: making beds, how to do cleaning properly, how to protect themselves from chemicals. It’s another job for me. The newly hired, they don’t have experience on the floor: how to sweep the floor properly, avoid accidents.” Naturally, some housekeepers get frustrated by what they perceive as sub-par performance by the workers around them, veterans and newcomers alike. Lucy

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Cusito says that she usually outshines her co-workers. “It’s so hard to clean this because all the sinks are already brown, because they are not very clean,” she says. “I do my very best to clean, and they really appreciate what I do. Even my supervisor, she really appreciates me. Sometimes the other workers, they didn’t do their best.” The reality is far from ideal. Julia Drake, a medical microbiologist working in a British Columbia public health lab, explains that “hospital staff needs to be well-educated, at every level, from the volunteers right down to cleaning staff up to the administrators about infection control prevention, and then of course administrators, government, and the general public, they all need to be educated.” Cleaning can be surprisingly technical and sophisticated work. Research has shown that UV light, steam cleaning, hydrogen peroxide vapors, and other specialized techniques are especially effective at eliminating pathogens from the hospital environment.25 As described earlier, the proper strength, type of cleaning product, and soak times are all important factors in effectively disinfecting surfaces in hospitals.26 Some germs are more vulnerable or resistant to certain chemicals or require a specific cleaning technique.27 When it comes to entering and working or delivering food in an isolation room, following proper procedures not only prevents hospital support workers from getting infected themselves but also keeps them from becoming super-spreaders who deliver pathogens as well as serving trays from room to room. To maximize safety, hospital support workers should have extensive preemployment training, continued mentoring by experienced supervisors and colleagues, and regular professional development refreshers and updates. Christopher Abrahms, an infection-control practitioner who works in a Vancouver hospital, says there’s much room for improvement: I think we can do a way better job in hospital cleaning and disinfection. . . . I don’t think there is near enough dollars or resources put into hospital cleaning. When I watch how a cleaner cleans, some of them are poorly educated, some of them are poorly motivated, but I also see them as highly overworked, and working in some aspects of nearly impossible situations with not enough support and not enough training and not enough knowledge about what they are doing. In some cases, there are simply not enough people to do the work, and that is driven by dollars. I think the hospital and healthcare system has not put enough dollars and resources and emphasis on building cleaning. . . . I think one of the key things is the environment. I think that cleaning and disinfection is key. I still think that there is not enough resource people doing cleaning disinfection.

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Winging It: The Dangers of Inadequate Training Given their training—or lack thereof—it’s inevitable that workers are often asked to perform tasks that they don’t know how to handle. They can refuse, but usually they end up “winging it,” a dangerous approach when there’s so much at stake. Catherine Ellis, housekeeper, explains, “They have asked co-workers to clean a room that’s cytotoxic [containing bodily fluids from a chemotherapy patient], and we have not been trained in it. Those co-workers were told they had to go in, and they refused, and then they got written up for it.” Freda Bansal says that she once had to call the company office to find out how to clean an isolation room, which is important to get right. She did her best based on the instructions given over the phone. “Sometimes it’s a bit scary,” Bansal says. Bansal is a veteran of the hospital housekeeping staff, but even she occasionally feels unsupported and underprepared. When working in the cancer ward, she still feels uncertain about how to handle spills of chemicals and medicines, some of which might be radioactive. “We are told to go clean it, so we just go,” she says. “They say put a gown on, put a mask on, double-glove it, and clean it. I’ve worked here six years, and nobody ever stood there and showed us exactly how it was done.” She has good reason to be concerned; hospitals are full of dangerous compounds, from medicines and cleaning chemicals to biohazardous waste. Support workers are often appalled to see new hires recklessly handling these hazards. “When a new person comes we try and teach them something our way. When this person doesn’t understand, we complain to the supervisors, but they ignore us because they’re so desperate for people they will hire anybody,” Bansal says. Juan Laguatan has often emptied and changed the garbage bins at the bottom of a chute, a task that’s pretty far beyond his job description. “We have to change the big bin and all the waste that goes down there,” he says. “It is not a housekeeping job, it isn’t. But I guess Regents thinks it’s our responsibility.” Casual workers such as Kerry Lyons are especially likely to find themselves in unfamiliar territory. She says that her calls for help are often ignored. “I already talked to one of the supervisors,” she says. “I’m a casual, you phone me, and I go to a different shift. I don’t know this job. You should tell me; you should train me. You don’t just push me to do it. But they say they don’t have time.” Gladys Adlao, housekeeper, once got a reprimand for refusing to clean a machine that she was unfamiliar with. Her supervisor said she should just go home if she wasn’t willing to finish her job. She responded, “I’m not trained there. I do the math, that in just a minute, if I broke the machine, it cost you millions [of dollars]. If you trained me first, I don’t refuse to work.”

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Fearing a reprimand for unfinished work, most workers just plow ahead and hope for the best, even if they don’t know what they’re doing. Jasmine Chaudry, a housekeeper at Mapleview Hospital, was required to clean up a toxic mess. “It was a spill site,” she says. “I didn’t have proper training for that cleaning, but I cleaned.”

The High Costs of Weak Supervision In any business, a commitment to quality should start at the top. But in many hospitals, the contractor management seems to be undercutting cleanliness. Maria Ganpule, housekeeper, says that supervisors told her to mind her own business when she noticed that high-risk rooms infected with MRSA or VRE were improperly cleaned: “On numerous occasions I talk to my supervisor and I said, ‘Look, this is not done.’ She said, ‘Oh you’re not supposed to go and check! You’re not, just blind your eye! You’re not supposed to go and check!’ Well some people shed the skin, and you see the skin, and on the bedrails, you see the bloodstains, and you’re not supposed to.” How could a supervisor dismiss bloodstains and stray bits of skin? Cleanliness simply is not their top priority—the profit motive drives the contractors to take on projects with minimal investment. While contract support workers lament the poor-quality work, they feel frustrated by the seeming ambivalence and lack of effort made by their supervisors and franchise contractors to improve the situation. In the world of modern medicine, the fundamental importance of hospital hygiene has been devalued and marginalized. Many workers told me that their contractor managers and supervisors were unsupportive. Or rude. Or just plain mean. The list of alleged shortcomings goes on. But cooks and cleaners aren’t the only ones struggling in the postoutsourcing world; the managers have a tough and largely thankless job, too. They stand in the crossfire between rushed, stressed-out workers and distant, profitdriven bosses. Not surprisingly, the turnover among managers is almost has high as it is among workers. Seventy percent of workers told me that they have a different supervisor than when they started. Of these workers, almost all said they have had three or more different supervisors since the beginning of contracting out. Managers now spend many shifts in crisis control mode. Because of chronic understaffing, they must shuffle support workers around to finish priority tasks, such as preparing a room for a patient waiting in a stretcher in the hallway. In some cases, they do the extra work themselves. When supervisors are forced to step in and do cleaning, the rest of their job description—giving guidance to other cleaners, making sure infection control rules are followed, sending workers to fill vacancies— falls by the wayside.28

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In the absence of consistent leadership, contract support workers have to adjust to each new supervisor’s personality and expectations. Doria Markopoulos says her department gets new supervisors every couple of months. “Some stay for a month, some for a week, some for three months,” she says. New supervisors often lack the knowledge and experience to effectively assist workers, she adds. “There is a learning curve.” Suzanna Lopez, dietary aide, says she sometimes ends up training her own supervisors. When they’re new, they don’t know what they’re supposed to do,” she explains. “So sometimes we even have to tell them, ‘You do this, you do that.’ ” A lack of supportive and experienced supervisors makes work even more difficult for hospital support staff. Imee Wenceslao, a forty-two-year-old Filipina dietary aide, describes the heavy turnover among supervisors at her hospital. “The first year I worked there, four of them quit. They were the old workers from before outsourcing. After five months, one by one they just quit because I think they just cannot agree with the manager, so they quit.” As she recalls, it was a big loss. “Those guys knew the kitchen. They are the ones who trained us, who taught us everything there.” The influx of new managers who arrived after contracting out dramatically changed the culture of the workplace, and not always for the better. According to Frederico Hilaga, cook, “a lot of supervisors that are getting in with the Lippor company, they don’t really have the training compared with before. They [used to be] just like a family. Because of what happened, those supervisors are gone.” He says now he has to make an appointment if he wants to meet with one of his managers—a far cry from the old days. Renata Patel says management went downhill after contracting out. “They’re not good,” she relates. “Before we had one supervisor. She was so nice. Before Lippor.” Her current manager is neither supportive nor helpful, she says. “We want to talk to manager, and he don’t want to talk to us. He said, ‘I don’t have time.’ He never shows up there in office. He doesn’t listen to anybody. He doesn’t talk to anybody.” She says that management ignores seniority in scheduling, and any complaints are quickly brushed off. “They say ‘the door is open, you can go home. Lots of people waiting here for the job.’ They say that, you know, we cry inside. Lots of ladies, we cry. We don’t want to go home. We need money.” Some support workers feel that supervisors pressed them to rush and cut corners, often at the expense of cleanliness and patient safety. Fundamentally, corporate managers and supervisors do not work for the best interests of patients. Rather, they are there to protect the best interests of the firms that employ them. These interests often clash, with cost savings taking precedence over quality. Tracy Melucci, housekeeper, says that her supervisor rarely does anything to make the hospital any cleaner or safer. “She’s on the computer playing FarmVille

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from Facebook,” Melucci says. “She’s visiting with her pets, her little friends in the office, or she’s drunk. The only time you see her is when she’s got to give somebody shit. She’s useless.” Melucci’s supervisor often asks her to rush with her tasks, but she doesn’t seem especially interested in real cleanliness. Melucci shares this anecdote: I was cleaning downstairs in the cancer clinic, and they were saying to me, “Oh, just do the sinks and the floors, the garbage. Just hurry!” But personally, I’m a cancer survivor, and I kept thinking, no, no, no. I have to do more. You have to wash down the chairs. You have to mop the floor. You have to clean their bathrooms. And then there’s that smell that comes with cancer. So I would do more and I’d go home and I’m going, man, I’m tired, and then I would complain to the manager at the time and she would say, “Well, cut down.” I said to her, “Where would you want me to cut? These people can die.” You have these people telling you, no, it’s not important. It’s a hospital. How can it not be important? Some support workers felt that managers played favorites or acted unfairly when it came to scheduling or assigning tasks. “There’s a lot of favoritism, everywhere,” says Dora Markopoulos. “It was stressful, feeling like you’re left out. Because when you’re doing your job right, why do they treat you [this way]?” Gaya Johl, dietary aide, suspects that her supervisor discriminates against some workers based on ethnicity. “I’m Indian, and my manager she don’t care about us, the Indian people,” Johl says. “She don’t like us.” Johl’s supervisor gets angry when she needs extra time to complete a terminal clean of a room contaminated with MRSA. “Those are cleaned differently,” Johl says. “Everything should be wiped down top to bottom. Floors, dusting, everything’s thrown out. So you need the time, and if you don’t have the time, you don’t finish other things.” Some of the worst supervisors cross the line between incompetency and flatout abuse. Maria Ganpule describes one offender: “If you have extra work and you ask for help, she will freak out. She will verbally torture [us]. She doesn’t respect [us]. She screams, and she doesn’t care where she is, [if] people are looking or patients are listening or they’re not listening. She will tell all that’s your duty, you have to do it, you finish it no matter how.” Ganpule says that her supervisor often ignores pages, telling her to get discharge rooms cleaned, causing problems for the entire hospital: “So they call constantly, call to her, and she doesn’t answer the phone. She doesn’t answer the pager. People are so frustrated. They say, ‘You don’t receive the page? You don’t receive the calls? What’s going on?’ People have gone to the human resources numerous times and talked to the human resources. She doesn’t respond to the phone and the calls!”

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Supervisors can be hard to find when they’re really needed. As Ganpule relates, “When we need help, then we call the call center, and tell them to page her on her pager. Then she says she doesn’t receive it. And she says, ‘Well, I was not in the area. I was outside. My pager didn’t get the message.’ So she has all these excuses. It’s very stressful.” Ganpule says her supervisor frequently picks on her and puts her down in front of patients. When she complained to management, her supervisor retaliated by auditing her work. During this audit, Ganpule’s supervisor checked rooms with “chairs and stuff like that sitting there for years, where dust will collect. So she comes and goes under the chair, ‘Oh look, she didn’t clean it. There is ten points cut off.’ She went to five of the patient’s rooms, and then she went in the offices, pick up the garbage can and she said, ‘Oh it’s not wiped properly. Dust everywhere.’ ” Once in this supervisor’s line of fire, Ganpule has been frequently challenged on the job. According to Ganpule, the taunts have included “Oh you can’t finish it, you’re not fit for the job. You have to go. Find another job or go to the doctor.” Ganpule turned to the union shop steward and human resources manager at the hospital for help, without success. Her co-workers went so far as to sign a petition to the contractor requesting new supervision: “They don’t want their supervisor and the manager on this site, because they don’t respect us, they don’t know how to talk,” she says. “Before [outsourcing], the supervisors were very supportive and listening, and they know how to handle the situation when it comes, because every day it’s different. Some days, you might not have discharge, some days you might have lots of work requests, and they know what to do.”

Sick Workers, Sicker Patients Ever since outsourcing, management has strived to keep workers from using one of their most important benefits—sick days. The contract allows them only four to six sick days per year, but, in reality, even these meager breaks are hard to come by. For a group of workers who often deal directly with vulnerable patients, sick days aren’t just a matter of personal comfort and safety. If a hospital housekeeper or dietary aide shows up to work with the flu or another infectious illness, the germ could easily spread, with serious negative consequences for patient outcomes. They are also less likely to do top-quality work when they’re sick. It seems obvious that sick workers need to stay home, but housekeepers and other support staff told me that their supervisors actively discourage them from missing a single shift—no matter the reason. They have many ways to discourage

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sick days. Some require a doctor’s note for even a single missed day. Some prefer harassment when a worker tries to call in sick. Daisy Utak says she’s reluctant to take a single day off work. “It’s like they don’t trust you so much when you say you are sick, because it’s more important to them to get the job done, and they don’t have much staff,” she says. “Right when you call, they will call back and ask how you are doing, or say that you need to go see a doctor, because a note is required. Of course it’s a hassle to go to a doctor and just get a doctor’s note for like a headache or your foot is sore.” Requiring a doctor’s note isn’t just a demeaning annoyance. Scheduling an appointment on short notice, getting to the doctor’s office—in practice, it’s a serious barrier to paid sick leave. Some supervisors asked sick workers to come in and work until a replacement was found, no matter what kind of illness the worker might be carrying. Mark Pilande, Housekeeper, explains, “Most of the time they are short of staff. When you call in sick, they say ‘Oh, can you just come here for two or three hours while they call for some other staff?’ ” Pamela Castles recalls one incident with a coworker, “She was vomiting, everything else. She called the call centre to contact whoever was on call and that she was really sick. There was no way she could have continued working. And she was basically told by the manager, ‘You’re not leaving. I don’t care how sick you are. You are staying because if you leave, I will make sure I fire you.’ ” Imee Wenceslao says that she has to “beg” supervisors to allow her to take a sick day. One incident stands out in her mind: “I’m not really feeling well, in the morning. You don’t know when you’re gonna be feeling sick, right? So in the morning, I phone, and he told me I am the third person who phoned in sick that day. He needs me to come in. I told him, ‘If I’m ok, I would be there right now. But I am not really feeling well.’ Then he just dropped the phone.” As a result of this sort of pressure, many workers don’t end up using their full allotment of sick days, which expire at the end of each year. Doria Markopoulos says, “I’ve been working for almost two years with no time off, so I don’t know how I survive. I lost my sick time because I didn’t use it.” They may not have training or adequate supervision, but hospital support workers are still a part of the health care team. When their work is devalued to the point of being outsourced, the hospital is left unprepared to prevent infections, unready to respond to outbreaks, and generally more unsafe for everyone who enters.

5 BREAKING UP THE TEAM

Prior to outsourcing, hospital support workers were part of the health care team. They might have been on the bottom rung, but they were still on the ladder connecting cleaners and cooks to doctors and nurses. But not anymore. Outsourcing has fundamentally compromised the teamwork required for effective infection control.1 Even if workers still had the benefits and wages they enjoyed prior to outsourcing, they still would be facing an uphill battle in their efforts to keep the hospital clean and safe. In a major survey, U.S. hospital administrators listed the loss of control and teamwork as a major downside to outsourcing cleaning and food service jobs.2 They hit the nail on the head. Outsourced workers now report to managers from their company, not doctors, nurses, or hospital administrators. The new model replaces cooperation and teamwork with a system of divided loyalties, a paradigm shift that seriously diminishes job quality and cleanliness.3 In the new system, hospital administrators have a single blunt tool to address any concerns about cleanliness—direct audits to check for compliance. Unfortunately, although auditing can identify problems, it cannot magically create the kinds of fundamental changes that will make a hospital any cleaner. Once jobs are outsourced, hospitals have almost no control over the who, what, when, why, and how of hygiene. Of course it doesn’t have to be this way. Simon Tierney, a senior administrator of a U.S. state program to reduce hospital acquired infections, explains that teamwork is the hallmark of clean hospitals: “Obviously the housekeeper is going to have a very different level of understanding than a registered nurse, the respiratory therapist is going to have a very different understanding than a surgeon. But in 67

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some hospitals they really have got their act together, they are focused on providing patient-centered care and they are part of a team, and they all recognize that unless every one of them is aligned that weakest link is going to bring them down.”4 The positive deviance and reform literature consistently finds that promoting teamwork is essential for reducing hospital-acquired infection rates and improving patient safety in a hospital.5 Aligning staff and communication across all levels is a challenge in any major institution. Outsourcing automatically breaks up the health care team, creating a whole series of weak links that never really come together.

Severed Connections In Vancouver, outsourcing of support jobs instantly eliminated the team-based approach to infection control in hospitals. Most dramatically, it cut down communication and cooperation between cleaners and front-line health care workers such as nurses. In Vancouver, as elsewhere, this breakdown has compromised worker and patient safety.6 St. Paul’s Hospital in downtown Vancouver is a case in point. Before the contracting out, the infection-control nurses had regular face-to-face meetings with the housekeeping supervisors. The nurses would explain any new protocols for cleaning, demonstrate the use of new equipment or safety devices, and discuss any ongoing outbreaks. After the contracting out, these meetings no longer happen; nurses must now phone a call center in the suburbs to even request a room clean after a patient discharge.7 Because support workers now report solely to representatives of off-site management, housekeepers can no longer formally ask for advice from nurses or other health care professionals in the hospital. Whether they’re cleaning an isolation room or dealing with a spill of medications or bodily fluids, they’re essentially on their own.8 They must make decisions about what is needed, safe, and essential in the complex, dynamic hospital environment, and they have to do it as outsiders. Their workload has increased due to staff cuts and systematic understaffing, which means they are now often responsible for an entire ward or wing of a hospital for their shift; many cleaners and dietary aids literally work alone for most of their shift.9

Management by Pager The new system hasn’t made life easier for people higher up on the ladder, either. If a nurse needs a room cleaned, he or she must file a work request through a centralized regional call center. The center then reroutes the request back to on-site supervisors, who then dispatch their employees to complete the tasks.10 Nurses

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cannot contact the supervisors directly; they don’t even have access to the supervisors’ phone numbers or pager numbers.11 The new systems of quality control are indirect and complex, with many “moving parts” and just as many opportunities for breakdowns and miscommunication. Repairing the broken connections would be a critical first step toward slowing down the spread of infections. Pagers have become some of the most important cleaning tools in modern hospitals. When a nurse calls the suburban call center to get a room cleaned, the center pages the on-site supervisor, who in turn pages the housekeeper. This convoluted communication system embodies the fractured and disconnected nature of outsourced support services. Many support workers say they are frequently paged to handle unexpected tasks, a burdensome and stressful part of the job. Freda Bansal, a housekeeper at Cumberland Hospital, says the constant interruptions are beyond frustrating. “They just keep paging us, constantly paging us, do this, do that,” she says. The new off-site request system is also a big time-waster for nursing staff and other health care workers. Nurses frequently complain about the time they spend on the phone requesting services instead of providing care to patients.12 At St. Paul’s Hospital, nurses reported having to make several calls before they received the support service they requested. In many cases, cleaners had to be paged multiple times over the hospital public address (PA) system to clean a bed or stretcher.13 Ideally, hospital workers should be ready to respond to anything that comes up. The convoluted communication system makes them less flexible, less responsive, and, ultimately, less effective. In spite of increasing infection rates, little has been done to improve or rebuild these networks destroyed by outsourcing.

Dangerous Miscommunication Communication breakdowns have become the norm. Many outsourced workers complain that they aren’t always warned ahead of time before entering the room of a potentially contagious patient. HIV, VRE, MRSA—it’s news to them. Louisa Talong, housekeeper, explains, “Whenever we ask they said, it’s private . . . [but] We are housekeeping. We have to go there and ask them to clean, but why don’t we have no right to know what kind of precaution we’re going to clean? At least we can protect ourselves.” Pam Castles, housekeeper, describes a time when an infection warning was posted in a patient’s bathroom, not on the front door. “I said, ‘Oh, my God, I forgot. I have X-ray vision. I can see through the wall.’ ” She says there have been other occasions when she has cleaned a room many times before learning that a patient has MRSA. This failure to communicate not only puts the outsourced support worker at risk but also endangers other patients; if the support worker

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does not know to follow proper precautionary procedures, he or she can spread pathogens throughout the hospital on clothes and mops. The lack of appropriate precautionary signage is a common complaint in Vancouver-area hospitals. Vincent Stevens, a nephrologist at a Vancouver hospital, told me about a time when he unwittingly entered an isolation room where patients were being treated for antibiotic-resistant infections. The front door had a sticker from housekeeping that said “clean” in big bold letters, but there was no indication of the true dangers behind the door. Inside, a resident who was completely oblivious to the threat was examining patients with a stethoscope without taking any of the necessary precautions to avoid the spread of infection. “I sent an email to the hospital administrators,” Stevens says. “It’s completely unacceptable.”

Unhealthy Communication Because of the wall erected between nurses and support staff, housekeepers often miss out on information that could be vital to their health and safety. Diana Mamaril, housekeeper, complains that she often doesn’t know that she is supposed to wear special protective gear until she has already entered a room. “Sometimes they don’t really care,” she says. “There is not much communication unless we are the ones who talk to them.” Mamaril says that she looks for clues that a room night be contaminated with an infectious pathogen after she enters. If she sees isolation gowns and gloves in the room, she suddenly knows that she’s facing more than she bargained for. Of course, that could be too late to prevent her from getting contaminated herself. Housekeepers aren’t the only ones left in the dark. Stevens has the same problem. “I mean the most confusing thing for me is not knowing when I walk into a room, and see a patient that is a known carrier of a MRSA or something,” he says. “I’ve taken to wearing gloves for everybody, and now and again I happen not to find a glove at the door so I walk in, examine the patient, and somebody whispers to me, ‘Oh, did you know they are positive?’ with no signage whatsoever. It is the most frustrating and ridiculous situation.” One unit in a Vancouver hospital responded to such breakdowns by bypassing the contractor and hiring their own supplementary in-house cleaner. Linda Raines, an infection-control nurse who works on this unit, explains: Here is a huge difference—we have our own personal cleaning person that is there from 7:00 a.m. to 3:00 p.m. every day. Katie is always there so you can build a relationship with her. Consequently she feels part of the team, and she takes some pride in what she is doing, and that is not nothing. I mean that is a huge budget thing, but that is not something

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they have anywhere else in the hospital. They are getting different people all the time. We have a relationship with Katie. If I’m like, “Hey Katie, I think you should go and redo this room or we need to this or that” and I know how to approach her and how she is going to take that and it is just better received overall.

Outcasts on the Job Outsourcing set hospital support workers apart from the rest of the staff. While some workers say they still have congenial relationships with nurses and other health care workers, they don’t have the same sort of professional rapport that they enjoyed when they were employed in-house. Mark Pilande, a housekeeper at Broadway Hospital, feels isolated from the nurses. “Sometimes they don’t even talk to you,” he says. “It’s because they are busy, too, or they think they are a little bit higher, so we feel that.” Of course, there were always some divisions—ethnicity, language, education, social status— between housekeepers and nurses. Outsourcing just made the gulf that much wider and more difficult to cross. Freda Bansal has had a similar experience: “When we started to work here six years ago, when I started in my X-ray area, there was two people who would talk to us. Now that we are [with] a private company, they don’t want anything to do with us. It’s like we are treated as total outsiders. The other hospital employees, some will talk to us, but in private. If I have a question, they will talk to me in private in a corner, but not if other people are watching us. I don’t know. After six years it’s still not changed. We are still treated like nobody.” The isolation of housekeepers makes it harder for them to do their jobs safely and effectively. Daisy Utak, housekeeper, says the lack of connection with other workers is a major source of stress. “Because we are from a private [company], I feel that I’m not part of their circle,” she says. “We feel that we are outcasts.” Maria Ganpule, housekeeper, says supervisors actively discourage support workers from socializing with other staff, even their co-workers. “I feel isolated because the company said you’re not allowed to talk about the company or talk to the workers,” she says. “So now we really have to watch what we say.” At Coast Mountains Hospital, support workers are discouraged from going to other floors or wards during their shifts, she says. As a result, they have no way to quickly consult one another about any sudden emergencies or unclear tasks, a situation that encourages bad decisions and improperly completed work. Erika Koch, housekeeper, says she felt much more connected when she had a similar job in Germany. “I worked in a hospital there, and we worked together,” she says. “One did the floors, the other did the cleaning. It was good.” Other

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research has found that teamwork between cleaners and hospital infection-control staff is stronger when cleaners are employed in-house than when contracted out.14 This teamwork is important for the quality of patient care. When faced with an outbreak or unexpected rush, this kind of teamwork, clear communication, and in-house know-how can prove crucial to a quick resolution.

Cut Off from Patients Spend any amount of time in a hospital as a patient, and you will probably see your housekeeper about as often as your nurse.15 The support staff makes up a major part of the public face of the hospital. But outsourcing has built a wall between support workers and patients. In many cases, the rules actually forbid workers from speaking with patients, a big break with tradition. As Freda Bansal explains, “They don’t like us talking to them because they [see it as] wasting time.” Nancy Pollak, researcher, notes that support workers were once major gobetweens for patients and health care staff: Although housekeeping is designated as a non-patient-care job, it is well understood in health care circles that cleaners often have important interactions with patients (even more so with residents in long-term care facilities). For one thing, they work near and around patients and will often be asked for something—a blanket, a cup—when no one else is close by. They notice if a patient has taken a turn for the worse or has a request and notify nursing staff accordingly. They may merely exchange a few pleasantries with a lonely patient.16 About half of the support workers I spoke with said they would like to have more time to interact with patients during their shifts. Freda Bansal explains, “I would really love to talk to people because so many of them are older people and their kids are all busy. At least two minutes [to say] ‘Hello, are you feeling much better?’ ‘Have you eaten your food?’ But there’s no time.” Maria Ganpule says that she has been warned not to talk to the patients. “We’re allowed to smile only,” she says. “Just smile at them, that’s it. When they say something just ignore and say ‘OK.’ You can say, ‘Hello how are you? How is your day?’ At least if you had time.” Robbing workers of their interaction with patients is just one more way cleaning companies make the job difficult and unrewarding. It also removes an important motivation to do a good and thorough job. When workers connect with a patient, they feel emotionally invested in the patient’s successful recovery. After outsourcing, contractors make it clear that patients are supposed to be ignored. Despite these rules to the contrary, some workers manage to slip in a few moments of genuine human interaction with the patients, as Imee Wenceslao,

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dietary aide, explains, “When I deliver the trays, the patients are all in wheelchairs. Sometimes they call me and say, ‘Could you please help me put on my bib?’ I help sometimes, but I know we’re not allowed to do that. Our manager told us before we’re not allowed to do those kind of stuff. We’re just about the food, and nurses are the ones who deal with it.” The hospital support workers who still make connections with patients say this is one of the most rewarding parts of their job. Wenceslao says she even manages to have running jokes with some patients. “There’s one guy there and he’s on a strict diet,” she says. “He tells me: ‘Do you have steak for me tonight?’ ‘Oh yeah, I have lovely steak for you.’ [laughs] And he cannot move his hand: ‘Ok, can you cut up my steak?’ So we pretend I cut up his steak.” Some support workers say that, while they were not officially prohibited or discouraged from talking to patients by their employers, they were simply too busy to exchange pleasantries. “In a sense, it’s like cheating some of the patients, because I cannot say, ‘Hi’ anymore, just ‘This is your tray, bye, bye,’ ” says Ida Bates, dietary aide. “I don’t even see their face anymore.” Surveys show that patients aren’t as satisfied as they used to be with the service of dietary aides, a fact that really rankles Bates. “Don’t expect me to have superb service when I have to deliver thirty trays, and I’m supposed to only have twenty trays,” she says. “I cannot say, ‘Hi, how are you.’ No more smiles. They are happy on the company side, but the patients are being cheated.” Many support workers have developed strategies to protect themselves from getting ensnared in conversations with patients that could cause them to fall further behind on their job tasks. As Kerry Lyons, dietary aid, explains, “If you deliver food to the old folks, they’re asking lots of questions. Sometimes you want to answer them, but you’re thinking, ‘Oh, if I’m going to spend five minutes, I’ll be behind.’ So if they’re going to ask me questions, I say, ‘I have to go call the nurse,’ even if I know the answer. Cause if you answer them they’re going to ask you another question.” Patients in certain areas of the hospital seem to crave attention. Amarita Kohli, dietary aide, works for Lippor in a long-term care facility attached to Alderwood Hospital. She says that talking to patients gives her job—and indeed her life—extra meaning: “You can see when you’re picking up [trays] the residents [who] didn’t eat. I ask them ‘Why you don’t like this?’ I talk to them. I like my work. . . . I feel good when I help someone. You give them a smile. I think, it takes like one second. And they don’t have any family coming there. Some of the residents, I love them. I want to make them comfortable as much I can.” Ruby Das, housekeeper, wishes she had more time to interact with extended care patients at the Drake unit in Forest Park Hospital. “Because I’m living with them, I have feelings for them,” she says. “Some of them they’re living two years, and die.”

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Support workers are asked to shoulder the emotional burden of working in the health care system without any of the benefits, wage premiums, or access to counseling, training, or other institutional supports typically available to health care workers. Instead, they are officially outside the health care system, trapped in a service job ghetto where they must contend with emotionally straining, stressful, and often isolating jobs without resources or support. It’s worth noting that some workers emphatically do not want to spend more time with patients. Some are afraid of catching an infectious disease. Workers who spend their time in wards with drug addicts or the mentally ill do not, as a rule, clamor for extra face time with the patients. But even these workers regret the lack of camaraderie and connection with other support workers and hospital staff.

Cleaning on the Margins Previous research has found that hospital support workers tend to feel invisible and devalued in hospitals.17 Outsourcing sends a clear signal that they are no longer a part of the hospital team and that their work is relatively unimportant. Social psychological research has shown over and over again that such low expectations can be self-fulfilling. When an organization or institution sends signals about the value of work—through wages, benefits, and work conditions—people begin to shift their performance to match these expectations.18 This, in combination with the desire of contractors to maximize profits, results in the further marginalization of cleaners and other outsourced support workers and negatively affects outcomes. Brian Johnson, a physician and professor of medicine in Vancouver, says that outsourcing probably has contributed to increasing risk of hospital-acquired infections, “just given the logic of capitalism, which is do the job for the least amount of money you can do it, and hope you can get away with it.” Outsourcing has reinforced the hospital pecking order. “In my own experience, I feel like because they’re nurses, they’re higher than me,” says Kerry Lyons. “I’m below them, so I have this kind of feeling of self-pity.” These feelings are sometimes exacerbated by a lack of warmth and respect from nurses and other health care workers, who unsurprisingly are frustrated by the new indirect system of communication or quality of work completed by some contract support workers. Lyons explains, “It’s very nice for us to hear even a thank you. Thank you, sometimes. Nurses forget those things. We’re working hard. We can see nurses work hard too, but if they could see our job, it’s really hard too. It’s nice for them to say thank you once in a while [small laugh], but sometimes they forget about that.” The new employment structure seems designed to breed conflict, contempt, and even turf wars between the support staff and health care staff. Instead of

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teaming up to deal with problems—whether it’s an overflowing bedpan, an unruly patient, or an outbreak of C. difficile—nurses and housekeepers often seem to work against each other. These broader issues are understudied and underappreciated by researchers and administrators alike. Jasmine Chaudry, housekeeper, says she has had several run-ins with nurses and other health care staff at Mapleview Hospital. “Because we [work for a] private company . . . we cannot touch anything, even if we use it for an emergency,” she says. “One time, I grabbed a pair of gloves, and it’s a big problem because a health care worker complained to my manager and everybody. Just a pair of gloves for an emergency, what can I do?” Similar breakdowns in teamwork and communication occurred in UK hospitals after outsourcing. A new liaison position called the “ward housekeeper” was created to open the lines of communication between nurses and contract cleaners, with the goal of improving cleanliness and reducing infection rates. Ward housekeepers clean essential areas and ensure other cleaners have adequate supplies. They even have the power to withhold payment or fire contractors who do not meet National Health Service (NHS) standards.19 A pilot version of this program is currently being tried at some Vancouver-area hospitals, which is a step in the right direction. Still, interviews with nurses in these wards at a UK hospital reveal that they continue to feel like they are working with their hands tied due to the complexity and unclear hierarchy of their work environment due to outsourcing.20

Whose Job Is That? In the chaotic world of hospitals, unexpected issues pop up on a regular basis.21 Housekeepers end up facing many situations that fall into gray areas: Is that potentially toxic and dangerous pool of chemotherapy medication of the floor really a housekeeping problem, or should a doctor or nurse take care of it? Prior to outsourcing, support workers enjoyed some latitude; if they felt that something was outside their job description, they could ask for help or at least a little advice.22 But now the workers face daunting dilemmas. Whose interests are they really serving? And who are they responsible to? Previous research on contracted out employees in organizations reveals that these divided loyalties resulted in contradictory pressures that fundamentally reduced workers’ commitment to the job.23 Other research shows that outsourced workers feel they are on the brunt end of organizational injustice, especially when they compare their circumstances to those working alongside them inside the system.24 In addition, many contingencies simply can’t be written into the contract, leaving out lots of things workers used to do and creating greater conflict and uncertainty.

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Juan Laguatan, housekeeper, says that uncertainty is just part of the job: Those who are newly hired, I tell them: What is the staff responsibility and your responsibility? Most of the time, they don’t know. Well, there are some occasions in one particular area, the housekeeping will do that, but in another particular area, they say don’t do that. There is some confusion sometimes. Like human waste on the floor. In some areas you have to get it. In other areas, the staff have to get it and the housekeeping people just disinfect it. There is confusion. We disagree and there are also big gray areas. It is not purely black and white. Disputes over gray areas spark passionate responses from contract support workers. Renata Patel, housekeeper, claims that health care staff often try to take advantage of the outsourced housekeepers, asking them to complete tasks that are outside their responsibility and their training: “[Nurses] never touch anything, and we have to do everything that is the nurses’ job. They don’t want to do that. They sit down and they talk and laugh. A poo and vomiting, they should clean, right? Lippor never signed that contract. Nurses clean that one, and housekeeping just go and disinfect it and mop there, right? And they don’t. The patient pee and they just leave it there. And everybody is busy, go here and there, do this, and the pee fell down on the floor.” Erika Koch also complains about being forced to clean soiled bedpans or commodes. “The first time I came to the station, I had to clean commodes,” she says. “I think there were twenty-two commodes in there, and this is really not a job for a cleaner. I was sick right away. We’re going to wash the floors; we’re going to sanitize everything. But why do we have to go clean shitty commodes?” According to their employment contract, support workers are not supposed to refuse extra tasks, even ones that are outside their job description. Their union instructs them to complete the work and then file a grievance after the fact. Of course, some will still refuse to complete tasks that seem unsafe or beyond the pale. Their refusals are sometimes met with an invitation by their supervisors to go home.

Lost Control Hospitals used to have some control over the workers who cleaned the floors and served the food. But now that private companies are in charge, hospitals are essentially powerless to improve service or cleanliness. Administrators can order inspections and audits, but the cleaning company will always have the final say. Health authorities and patient advocacy groups are even more impotent to force funda-

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mental changes. When government institutions enter into contracts with private service providers, the system becomes less transparent and less open to reform. After outsourcing, hospital and health authority administrators in the Vancouver region no longer have control over the products and chemicals used by support workers to clean their hospitals. They cannot require the latest or most effective cleaning techniques.25 Yet, despite the health authority’s complete lack of power and oversight, it must absorb the costs of any consequences or missteps, including closing down wards, completing decontaminations, and treating hospital-associated infections.26

The Limits of Inspections and Audits The goal of outsourcing of services is often to realize immediate cost savings while measuring and improving quality and exerting control through inspections and audits. As many of these managers learn in the long run, what largely remains is an illusion of control. The hospitals are dirty, the food is worse than ever, and patients and staff alike are endangered by cut corners, incompetence, and mistakes. Why has outsourcing been such a disaster? For one, the assumption that audits and inspections would guarantee both contract compliance and high-quality work turns out to be deeply flawed. Privatization and outsourcing resulted in a reduction in transparency, accountability, and control. One specific problem is that random audits in Canada—as well as in the United States and United Kingdom—are visually based, which means nobody tests to determine whether surfaces are contaminated with germs or chemicals.27 Furthermore, even when a cleaning company fails an audit, there are almost no sanctions beyond a promise of more inspections. These follow-up inspections are usually announced well ahead of time; for that day, at least, cleaners are under intense pressure to do a passable job. Unsurprisingly, in Vancouver-area hospitals, failed inspections rarely lead to any lasting actions or improvements. In the short term, resources are redirected to the problem area by the contractor in order to pass the subsequent re-inspection. Although this appears to be a positive response, it often leads to important resources being directed away from other areas to address the problem and pass re-inspection.28 Moreover, often it’s merely a quick fix. Once the re-inspection is complete, the additional resources and attention diminish, and the situation often returns to its failed state. Francine Rankin, housekeeper, recalls, “A few audits ago we got a really low score and it was all the stuff I used to do. So when the next audit time came they got all the casuals in to do the job I used to do, bring the scores up. And it worked. They got a 94 which is something—we’d never get a 94. But it took a whole bunch of casuals and overtime to do it.”

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Such quick fixes to pass an inspection do not improve hygiene in the long term because they don’t fundamentally address the underlying systemic problems, such as inadequate training of contract employees, high turnover, and understaffing. Renata Patel explains, “When the Health [Authority] come and check the areas and they give a low audit [score], they come and talk to my manager. Then they complain to us. ‘Why you guys get low audit? You guys didn’t do this, didn’t do that?’ We’re short of staff, that’s why. And we have only two hands! We can’t do everything.” The current inspection regime in the Vancouver area requires a complex matrix of goals and targets that are often work against patient safety. For example, a dangerous incentive is created for contractors to emphasize the speed of terminal bed cleaning, something that’s easy for the auditors to measure. The quality of the disinfection is irrelevant.29 The audits also don’t give any weight to the comments or concerns of the housekeepers. Nancy Pollak, researcher, paints a damning picture of the current system: “A window sill with a discarded coffee cup will receive the same rating as a window sill with grimy dust; yet the former is a short-term bother while the latter could be a sign of real trouble. Further, the audit form is unable to capture a pattern of grimy dust in several rooms, over several weeks.”30 The current audit system is useful for gathering superficial tallies and statistics, but it does not address the actual problems that could endanger patients and staff.31 The outsourced company that completes these audits has extensive experience and, to its credit, it has been tweaking its methodology and approach. In the past, each of thirty-one items on the checklist carried equal weight. That meant, as Pollak explains, “a patient’s room could have an unsatisfactory bed, toilet, IV pole, and monitor, and still earn [a passing grade] if all other items were satisfactory.”32 This is a far cry from hotel room inspectors, who may remove a star from the rating of a hotel if a hair is found in a bathtub.33 Yet patients are much more vulnerable than most hotel guests. In addition, random inspections often miss crucial areas of the hospital. If inspectors were truly concerned about preventing hospital infections, they would spend extra time and resources monitoring the surgical units, operating rooms, burn units, HIV/AIDs units, and dialysis rooms during every inspection. Instead, random inspections can take place in less critical areas, perhaps the physical therapy rooms or conference rooms. The company contracted to inspect hospitals in British Columbia now gives extra weight to the inspection scores of sensitive areas, and there is talk of adopting more advanced technologies and inspection methodologies. Organizational and ideological politics can further hamper inspection and audit systems. For example, the same managers and executives who decided to outsource in the first place are often in charge of the audits. Naturally, they have a stake in making sure that the audits don’t make their decision look short-sighted or reckless.34 These powerful actors can resist any kind of inspection that would

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reveal serious systemic problems. Inspection and audits systems can be and are manipulated, managed, and tamed, especially by those whose interests are not exclusively focused on reducing hospital-acquired infections.35 Without taking a much closer look at the cleaning practices in hospitals, and using the right inspection tools (going beyond visual inspection), it is impossible to appreciate the real risks to patients, staff, and the community.

Limited Tools in the Fight against Infections In the aftermath of outsourcing, administrators have a limited ability to address the systemic problems that lead to contaminated hospital environments. They simply have no voice or power when it comes to hiring, training, and staffing.36 Random inspections can lead to some changes, but they don’t result in fundamental, longterm improvements in performance and quality. The Nanaimo Regional General Hospital on Vancouver Island, for example, supposedly beefed up its cleaning protocols after outbreaks of C. difficile in 2008–2009. Of course, the hospital didn’t really do anything to make it easier for housekeepers to do their jobs, and it wasn’t long before it was battling yet another outbreak of C. difficile, and a new norovirus outbreak in 2010.37 Dr. Robert Stanwick, chief medical officer of the Vancouver Island Health Authority, recommends eliminating “scheduled audits” and re-inspections and replacing them with “real-time, unannounced monitoring of actual practices.”38 Many hospitals have inspection systems that do not directly address microbial contamination. As it is, many inspectors give a passing grade to a room or a ward that is rife with germs. When it comes to tracking microscopic germs, visual inspections simply aren’t adequate. Instead of simply looking at an item or surface and declaring it to be clean, inspectors should regularly swab and culture high-touch surfaces or use UV light to check whether the surfaces are actually being disinfected as recommended by infection-control specialists.39 A revealing study from the United Kingdom shows just how valuable UV testing can be. Ninety percent of hospital rooms in the study passed a visual inspection, but a UV test showed that 100 percent were actually unsatisfactorily cleaned and that 90 percent of the so-called “clean” rooms had sites with unacceptable microorganism contamination.40 If hospitals really want to reduce rates health care–associated infections, they will have to improve infection-control training for all health care workers, including front-line housekeepers. The Health Information and Quality Authority in Ireland already recommends this commonsense step.41 Of course, contracting out prevents the hospital from controlling the training of the people cleaning and serving food in the hospital. This relinquishing of control is one of the inherent problems of outsourcing.

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Vincent Stevens has seen some shocking lapses of protocol. “I’ve seen people who don’t wear protection when they are handling patients with antibiotic resistant organisms or C. diff. or whatever it happens to be,” he says. “I’m not sure if it is laziness or ignorance, but clearly they don’t understand the implication of what they are doing.” Linda Raines, nurse, shares her impressions of the situation: “It is not that they don’t want to do what is best for the hospital and the patients and their job. I think a lot of it is education and ongoing kind of motivators. For instance, cleaning staff often come in, they put on one set of gloves, they do not change their gloves nor wash their hands when they are emptying every single garbage can in the entire unit, even in the MRSA/VRE rooms. Do I ever see them put on yellow gowns when they go into those rooms? Very, very, very uncommon.” In 2012, some more advanced inspection techniques have begun to be used in Vancouver hospitals. Carol Werthers, a senior infection-control administrator, explains the progress: “We are starting to do UV audits. Formerly the audits were mainly what I would call ‘hotel clean’—dust bunnies and shiny mirrors—but it wasn’t really clean. Now to be fair, I don’t know if all contracted services are there yet. In some ways we can hold the contractors more responsible and put it in as part of their contract.” Werthers cautions that the process of improving audits is really still in its infancy. She explains that there’s still work to do: “We have got agreement here in-house that they meet with our senior infection control practitioner every week. We go over all the stats for AROs [antibiotic-resistant organisms], we try to move personnel around to address it and whenever there is an opportunity we do what we call ‘spring cleaning.’ If it is a long weekend and admissions are down we try to clean other areas additional to what they usually get and I have to say that the contracted company has been very good with that.” Improving audits is a step that is long overdue. But there are still huge gaps in the system. Surprisingly, infection-control nurses and other experts working in the hospital no longer receive the results of housekeeping audits. Alison Walters, nurse, told me that she never saw a housekeeping audit being performed and has no idea how often they occur—or supposedly occur. “I like clean hotels, and I think a hospital should be like a clean hotel if not cleaner,” she says. “They have inspections. Does nobody come in and inspect the hospitals? Are there no hospital inspectors? I don’t know.” Post-outsourcing, audits and inspections are about the whims of the contractor, not quality and cleanliness. While audits and inspections may encourage contractors to live up to minimum standards at minimum cost, they do not encourage them to strive make the kind of fundamental improvements that will improve the safety of the hospital environment.

6 DOWN AND OUT IN VANCOUVER Struggling, Stressed, and Exhausted Hospital Support Workers

Hourly wages, injury rates, staffing levels—statistics can tell us a lot about the struggles of hospital support workers in the aftermath of outsourcing. But, as I talked to housekeepers and dietary aides, it became clear to me that their daily experiences tell the real story. These workers aren’t complainers or malcontents; they are people trying to get by in incredibly difficult circumstances. And because their work directly affects hospital hygiene—and thus a patient’s risk of coming down with a hospitalacquired infections—their plight should be everyone’s concern. Their lives mirror the plight of a growing number of workers at the lower tiers of the service sector, who struggle to make ends meet with inadequate wages and benefits, even in a “progressive” country such as Canada. The growth and expansion of the low-wage service-sector workforce is increasing inequality and fundamentally reshaping post-industrial economies and societies globally. The decision to outsource hospital support jobs also has had a direct negative effect on the families, especially the children, of hospital support workers. Their stress does not stop at the workplace door, and it saps their will and strength. The consequences for these workers and their families illuminate the challenges faced by a growing number of working families in the new economy internationally.

Hospital Support Workers’ Stories Eve Nicdao Eve Nicdao was born in Loag City, Philippines. She moved to Canada in 1995 when she was in her mid-forties to find work. Before coming to Vancouver, she 81

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worked as a nanny in Europe to support her now-grown children back in the Philippines. “It was difficult for a mother to leave her children back home and move to another part of the world to find money to support them,” she says. She left her two children in the care of their grandparents. “I would love to see myself with my children, and a better life in my old age,” she says. “But I don’t know if I see that. It’s hard.” Nicdao has an undergraduate degree in banking and finance from the Philippines, but the best job she could find in Vancouver was a housekeeping position in a hospital radiology department, working the 3:30 to 11:30 p.m. shift. Her regular job routine includes cleaning up patient treatment rooms and picking up hazardous chemical waste. Despite working full-time at the hospital, she does not earn enough to pay for rent and groceries, so she works at a second job in the seafood department of a major supermarket chain. Her job there consists mainly of wrapping fish. “I am more a fan of wrapping fish than cleaning,” she reflects. Between her two jobs, she estimates her total annual income to be $28,000. She shares a one-bedroom apartment with her sister and niece. “There’s no privacy, if you want to have a quiet morning, you cannot have,” she says. They pay $768 per month in rent; in Vancouver, that’s not enough to get anything especially spacious or comfortable. The apartment is cold in the winter because the landlord controls the heat, but it’s still warm enough to support a thriving community of mice and cockroaches. She finds herself falling further into debt. She owes $16,000 on her credit cards and has taken out $5,000 on line of credit. “It’s really difficult,” she says. “I don’t have enough to buy my food. I don’t have enough to put into savings.” They have been unable to pay their rent on time twice in the past year. “The owner was so mad,” she recalls. Overall, the pressure of balancing two jobs and falling behind on her bills has her feeling like she is caught in a downward spiral: “I cannot rest properly. I cannot take care of myself. I don’t have time. I don’t have time to do my hair, no time to go and have fun with my friends. . . . It’s not good. I don’t feel like cooking. I don’t feel like cleaning the house when I am at home. I can hardly wash my clothes. If I am home I just want to rest.” When her mother died recently, Nicdao used her vacation days to return to Philippines for the funeral. This year, she says, “I’ll be having my holiday next month, and I’ll just stay home.” She laments, “I used to go and visit my cousins in North Vancouver, and now I never go.” Working two jobs simultaneously prevents her from being involved in any clubs, groups, or community activities. Despite the challenges, Nicdao says she feels good about her job. “I love to serve people,” she says. “But I am not happy with my salary.”

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Peter Wu Peter Wu began working as a dietary aide at the ICU of Mapleview Hospital in the early 1980s and later became a housekeeper. For nearly twenty years, his unionized job at the hospital provided him with a decent wage and benefits package. Since outsourcing in 2004, however, his wages have been cut from nearly $20 per hour to $13. When his job was outsourced, he received a pink slip notifying him that he had been laid off. “I want to work, so I reapplied to the company and got hired back,” he says. He soon discovered that many benefits had vanished. The contractor initially refused to pay him extra for overtime hours, which he knew was a violation of the labor code in British Columbia. In the end, he complained and got the overtime he deserved. As a result of outsourcing, Wu lost even his hospital parking privileges; as a contract employee he is no longer considered a staff member of the institution. He used to be able to park in reserved spots in the hospital garage for the staff rate of $60 per month. Without this parking benefit, Wu and hundreds of other contract support workers now have to spend extra time every morning looking for a parking spot around the hospital neighborhood. Often, they end up walking several blocks (through the rain) to work. The new reality has taken a toll on Wu’s family. “After privatization, we have a lot of financial disappointments,” he says. His wife couldn’t work after suffering injuries in a car accident. “I’m by myself [working to support the family] for over ten years,” he explains. “I need to work in the hospital. I have to support my children and also the family. It’s been tough.” Beyond wages, he reflects on how working night shifts negatively affected his parenting: “When I picked the evening shift, and then later on I do some night shift work, I had a really hard time. . . . I used to work graveyard in the OR, and get off work at 8 a.m. And that time I take my son to the park, and then at 8:30 a.m. I’d be home but so tired, and my son wakes up and wants to play. He doesn’t know I work night shift. That was a tough time.”

Tracy Melucci From the outside, it may seem like Tracy Melucci, a housekeeper, has it made. Years ago, she was able to make a down payment on a house with the windfall from a family inheritance. But, as she explains, the house has been become a facade of financial security: I don’t have any heat. I need a new furnace. This one here that I have in there right now is, I think, probably thirty or forty years old. And I’m

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afraid to go asleep with it on. Yes, the heat’s been gone for four years. I can’t afford the fuel. Not with my wages. I don’t think I’m going to live through another winter. Last year when it was 19 [ºC] below zero, I don’t know how the heck I woke up in the morning because I actually was prepared to go. So when I woke up I was really surprised. I thought, I’m still alive. Melucci’s house is also a breeding ground for mold. “No matter how much you bleach it, it comes back,” she says. “It’s coming around the ceiling and up the wall, especially in the bedroom and in the bathroom.” She borrowed money from her sister to fix exposed wiring because the insurance company was threatening to cancel her coverage. But that hardly solved the whole problem: “My sister paid for the electrical upgrade. It wasn’t enough. You couldn’t run the dishwasher and the microwave and the TV at the same time. You either used one or the other one. If you live by yourself, it’s okay. But if you tried to do laundry and cook. . . . So she [her sister] paid to have it [repaired] and it was about $3,000 bucks, and I have to pay her back eventually.” Melucci’s phone has been cut off several times, and she feels that both the phone and electricity will be cut off soon because she can’t afford to pay her bills. She does manage to cover her $803 monthly mortgage payment. “That is the first thing I pay because even if I’m in a cold house I’ve got shelter,” she says. Melucci owns a car, but it’s not much. “A 2006 Chevy Aveo. That is what I affectionately call my pension fund, ’cause that’s where my RRSP’s [governmentsubsidized retirement savings] went,” she says. “I needed a car to go to work ’cause when you work till 11 p.m., and you got to walk by a park to get home. There’s been a lot of drug deals at the park and beatings and 11:15, 11:30 p.m. at night. If it’s snowing and it can’t be helped I’ll walk. I’ll carry a baseball bat, but I’ll walk.” She says her gas budget is $5 a week. Even with such scrimping and saving, she says her future looks bleak: “If things keep going the way they’re going, I’ll end up losing my house because I won’t be able to keep it up. I really don’t want to go down that road. I have three dogs. They keep me company. They’re my pals, you know. I hate going home to an empty house, and I have this welcoming committee, when I walk through the door. It’s just the best. And [heavy sigh] there are times that I feel that I’m probably going to have to give them up because I won’t be able to feed them much longer.” Although she has been working full-time in the health system for years, Melucci is increasingly concerned that she will never be able to comfortably retire: It’s insane. When you work full time you should be able to support yourself comfortably and when I say “comfortably” I mean I should be

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able to throw $50 bucks into my savings account after everything’s paid, everything’s said and done. I should be able to heat my home properly. And I should have something going into a pension plan without having to ask my kids to help me out. I’ve always believed because watching my people as they grew older, they mellowed out, they relaxed and they enjoyed life. When is it going to be my turn, you know? I’m not ready to retire or anything, but I’m a grandmother and at this age, at fifty-two, I should be able to start looking down that road and saying, okay, I’m going to retire on that day. I have $6.56 in my savings account as of this morning. And I borrowed money from my granddaughter so I could have dinner. . . . So when does it get easier?

Gladys Adlao She’s ashamed to admit it, but Gladys Adlao, a housekeeper, lives in a subsidized public housing complex. She pays $474 per month for a two-bedroom apartment. It’s an incredible bargain by Vancouver standards, but it also comes with all of the headaches you’d expect from public housing. The suite has problems with leaks. “Our one bedroom there, the floors are wet, because there’s the terrace of the third floor right, so if it’s raining, the water comes,” she explains. The leaks help fuel the growth of mold, which is practically impossible to get rid of. The apartment is home to mice, rats, and a healthy population of ants. The toilet has never been replaced since the building was first constructed. On cold days, even her space heater can’t overcome the drafts. In addition, like other residents of public housing, she constantly worries about crime. She says her neighbor is a drug dealer. Break-ins are common. Despite these issues, Adlao hopes to stay in her apartment. As she explains, “I will stay here until I they ask me to move [laughs]. This is low rent. I don’t worry if I don’t have job. Here, if you don’t have job for a while, you go to the manager, and say this is the only money I earn, so they lower it. If you increase your salary, they are going to increase your rent.” While she was initially happy to get her hospital housekeeping job to supplement her income as a caregiver of an elderly woman, Adlao, a single mother, faces serious challenges balancing work and caring for her two children: “I do the morning shift, from 7 a.m. ’til 3 p.m. I ask my mom to dress my kids, and then I ask my neighbor if she can bring my daughter [to school]. And I pay her too. And after school my mom stays here. And then after 3 o’clock I get home and I cook, and then at 8 o’clock at night, I’m going to [look after] my old lady [her care client]. I feed them before I leave, and bath, and then ready for bed. And then I’m going to work, again. Again! [sighs].” Her children are increasingly

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aware that she does not sleep at home. “They say, ‘Mom, you always work, you don’t sleep here with me anymore.’ I feel very sad. . . . it’s so hard for me to sleep without them,” she says. After her night shift as a caregiver, Adlao gets up at 5:30 a.m., bathes and feeds her client, and then leaves for the hospital to begin her day shift once again. She does not see her children until they are home from school and mostly communicates with them by telephone. Over the years, the lack of time she has to spend with her children has become increasingly frustrating: “So many years, so many years, and the hard time for me is when they ask me ‘Mom, you always work, didn’t stay, didn’t stay with us.’ Sometimes, I feel like I don’t want to see them because I’m crying in front of them. Sometimes I’m driving and asking myself, what kind of life I have. And it goes on and on and on . . . ”

Linda Appleton Linda Appleton is a fifty-year-old single parent of two teenage boys who works cleaning hospital operating theaters at Lexington Hill Hospital. She lives in a basement suite, which she rents for $800 per month. “Well, the two bedrooms, the boys have their own. I sleep in the living room,” she says. “Yeah, it would be nicer to have a little bit more space. But it’s too expensive, way too expensive.” She has had her phone cut off, “I got my phone cut off. I disconnected it ’cause I can’t afford it. . . . No, I haven’t reconnected.” Despite working full-time, she has serious challenges making ends meet. “Well, my rent’s $800, my Hydro [electricity] is $100 every month. And then I’ve got my food bill, cable, my line of credit I just pay the interest on. I’ve never used my Visa in three years so it’s just paying the monthly payment on that. I pay $100 on that. . . . It all adds up.” Her finances are tough on her kids: “They don’t have what they used to have. . . . We’re on a tighter budget now. A very tight budget.” In the past, “once every Friday, it was the weekend, I’d take them to the movie. They’re involved in sports. I can’t afford it now, so they don’t get it.” She has no vacation plans, “I can’t. I can’t afford it. I live off my credit card because $800 every two weeks doesn’t cut it.”

Outsourced Jobs, Struggling Families In Vancouver and across the developed world, outsourcing has destroyed many middle-class jobs and replaced them with low-wage, insecure, low-road jobs that keep families mired in working poverty.1 Katherine S. Newman and Victor

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Tan Chen, sociologists, describe these families as part of “the missing class.”2 While their earnings are enough to put them just above the poverty line and prevent them from accessing government assistance, they live paycheck to paycheck, often only one unexpected expense or missed check away from serious hardship. This is not a small part of the workforce. In the United States, a Wider Opportunities for Women’s recent report estimated that 45 percent of families earn less than what is required for basic economic security.3 Like many in the missing class, Gaya Johl, mother of two, earns too little to support herself and her family but too much to qualify for public assistance. She pulls in about $20,000 per year, not quite enough to stay afloat. “So I pay insurance and gas and parking. Then I pay the rent and groceries. I don’t have the money, so I use my credit card and it’s going higher and higher.” Still, she does not want to take on a second job. “If I work another job, then I have no time,” she says. “I don’t want my kids to turn out the wrong way. . . . I don’t want them to just suffer like me.” Of course, all sorts of families are struggling in today’s economy; they’re called the 99 percent for a reason. Lost wages, second jobs, and unemployment have almost become the new normal. But people at the lowest ends of the employment ladder have far fewer resources to cope with such hardship. They can’t draw on savings. And they generally can’t hire someone to clean their homes or take care of their children. Many hospital support workers told me that after they come home from their formal job, they have to begin their “second shift” as house cleaner, food preparer, chauffeur, or caregiver.4 As Jody Heymann, McGill University political scientist, points out, such multitasking raises some difficult questions: “Who is currently taking responsibility for children’s health when their parents are working? Who cares for children when they get sick and are not allowed to attend child care or school? Who cares for infants and toddlers who cannot be left home alone sick? Who cares for schoolage children who are too sick to care for themselves but not sick enough to be in a hospital?”5 Long working hours, unpredictable schedules, and low wages create serious challenges for working poor families.6

It Takes a Paycheck to Raise a Child Here’s a news flash from the front lines of modern life: Children are expensive. Clothing, food, child care, fees for field trips and sports—it never ends. In the United States, it costs an estimated $152,600 to raise one child through age seventeen in a two-parent middle-income family.7 And that does not include the rapidly increasing cost of university tuition!

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Juan Laguatan, housekeeper, explained that, when his kids need money for school fees or the latest video game, he sometimes caves and puts it on Visa. “That’s the problem. My credit card is too high. My children say ‘Oh Dad, I need. . . . ’ And I say ‘Yeah, I know.’ My credit card debt is high because of this.”8 Ruby Das, housekeeper, could not enroll her daughter in an art program because she couldn’t afford the fees. Given the important role of extracurricular activities for reducing social isolation and building social and cultural capital, the exclusion of these children from art, music, sports, and other kinds of activities and programs could slow their academic and social development, disadvantaging them in comparison to their more fortunate peers.9 Khalid Imani, hospital cook, wishes his son could participate in more extracurricular activities. “After school, I take him to Tai Kwan Do class. I basically cannot afford to take him to any other activities, because you have to pay,” he says. With a new baby in the house, he acutely feels the pain of his meager paycheck. No. It’s not enough. [laughs]. It’s not enough to do what I want to do. . . . I want to live in a bigger place, so all the kids to have own room and not to be crowded. And for my son, to take him on weekends, there’s swimming, there’s soccer. When all the bills build up together and you have to pay them, then you realize it’s short. I am not eligible for GST [sales tax rebate] and when it comes to the child-credit tax [rebate], just we get minimum. I buy a can of baby formula every three days. It’s $20 bucks! What do I get for work, $72 dollars [a day]? Not even enough extra for a can of milk. What about other expenses, diapers, babysitter, all those? As demonstrated by Kathy Edin and Laura Lein, sociologists, in their book Making Ends Meet, children suffer the consequences when their parents must choose between basic needs. Even as children get older and require less child care because of school, it is challenging to raise a family on very limited earnings. Lily Oracio, dietary aide, is trying to single-handedly support her son as he attends university. “It’s very difficult,” she says. “He graduates next year. I still don’t know when he graduates if he’s going to give me money because he has got student loans too,” she says. Oracio makes about $18,000 a year. “I’m a single mom all my life,” she says. “It’s hard. No support from the father. No nothing.” Because she is just above the poverty line, the only government assistance she’s eligible for are low-income tax credits. While these tax credits are helpful, they are not enough to give her any sense of financial security.

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Coping Strategies Of the outsourced hospital support workers interviewed, 68 percent earned less than $30,000 the previous year, while 14 percent earned less than $20,000 per year. Almost three-quarters of the workers reported that it was either “difficult” or “very difficult” to pay their monthly bills. With such low incomes, these workers resorted to a range of strategies to try to make ends meet. Some took on boarders or international students to help pay for housing expenses. Others focused on reducing household expenditures, which sometimes meant cutting back on extra-curricular activities for their kids. Still others took on second and third jobs. In fact, 30 percent of the support workers said they had more than one job. Workers often have to be resourceful and tap their networks for help. Maria Ganpule, housekeeper, is separated from her husband. To survive on her wages, she bargain shops and relies on food donations. “We just try to make ends meet,” she says. “We find the cheapest things. Sometimes the store is ready to clear things. Foods and vegetables to keep a little [past expiration]; it’s not that bad, it’s still edible.” Others report having to rely on the charity of others, something that chips away at their pride in having a “real” job. Many workers turn to credit as a short-term solution—it’s not long before they find themselves buried in debt. Chin Lan Shao, housekeeper, says she and her unemployed husband currently owe $30,000–$40,000 on their credit cards. To save on housing expenses, some workers opt to live with their extended families. Gaya Johl, dietary aide, pays $550 per month to rent the basement of her brother-in-law’s house. She and her two children live in the basement, while her husband, mother-in-law, two brothers-in-law, and sister-in-law live upstairs in the main house. Understandably, she described her housing situation as “very crowded.” It also makes it harder for her to get a decent night sleep before her shift at the hospital.

The Challenges Created by Low Wages Outsourced hospital housekeepers are acutely aware of the income gap that now separates them from hotel maids, university janitors, and other cleaners outside the health care sector.10 Daisy Utak, housekeeper, works next door to an organization that pays its housekeepers $18 per hour, nearly 40 percent more than what she earns doing similar—but more dangerous—work. “We are housekeeping in a hospital, so I thought that we should be getting more because of what we deal with and how important our job is to the health care,” she says.

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Even after several years of adjusting to life after outsourcing, Grace Caabay, a sixty-four-year-old dietary aide, still struggles to accustom herself to her new income: “It’s hard, in terms of salary. It’s not enough. But $13 [per hour]? Boy! To be honest, I’m satisfied with my work, not with the pay.” Low wages result in challenges to secure decent housing and making ends meet.

Housing Struggles The outsourcing of hospital support jobs in the Vancouver region occurred at a time of soaring housing costs. Over the past decade, real estate prices have approached levels worthy of San Francisco and New York. Rents, while not as sky high, have also increased, especially in better neighborhoods. With such high living costs, many hospital support workers were unable to afford quality housing. Even more serious, five outsourced hospital support workers I interviewed reported experiencing a spell of homelessness in the previous five years. Almost all reported having some kind of housing problem, such as broken appliances, roof problems, pests, and leaks. Adya Maibam is a forty-seven-year-old Indian dietary aide who lives with her husband, her own three teenage children, her brother in-law and his three young children, and other in-laws. A total of twelve people share one house, along with more than a few rats. “The kids come from school, then its crowded,” she says. “Especially the younger one’s when they come, they shout, they are noisy.” Juan Laguatan’s family lives in a one-bedroom apartment. The rent is $950 per month. “It is a basement suite. One bedroom. My little girl is in the bedroom and my son just sleeps in the living room,” he says. Beyond the cramped conditions, the apartment has rats, mice, and roaches, which he refers to as the “unwelcome visitors.” As is the case for many tenants in Vancouver, the family is unable to control the apartment heat settings. “We live in the basement. The control is up to the landlord,” he says. Laguatan says he recently fixed a leaky faucet by himself—but now the oven isn’t working.

Health Expenses Ironically, but unsurprisingly, outsourcing also slashed the extended health benefits of hospital support workers. Catherine Ellis, housekeeper, explains her situation: “Now we’re all on the lowest of the medical [benefit plans]. We’re allowed for our extended dental, we’re allowed one visit a year to the dentist for cleaning, and yet most dentists want us in for two. It’s just the little things

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like that. You don’t look after yourself because you can’t. It’s just basic medical. Our extended medical covers glasses a little bit. It covers our dental very minimally, and doesn’t cover dentures at all. And it doesn’t cover, like, hearing aids or anything like that at all.” Support workers are now expected to cover a greater proportion of the costs for prescriptions, dental, vision, and other kinds of “extended” health care services than when they worked in-house. Dietary aide Adya Maibam says, “I never go to dentist. Expensive! I went two years ago for my root canal, he said ‘$600 dollars.’ I can’t afford that much money because my plan’s not very good now.” Increased co-payments are an additional source of strain for some workers. This is especially true for workers with chronic illnesses requiring expensive prescriptions drugs. As a result of her limited health coverage, Renata Patel, housekeeper, has medical expenses that now consume a larger proportion of her already-reduced monthly income. As she explains, she barely has enough money for both rent and medication: I have a heart problem. I have a stent here. I have to take the tablets. Blood thinners, cholesterol [medication]. And the tablets are so expensive! So expensive. And I have to buy every three months . . . altogether maybe $700, just my tablets, for a three month’s supply. I pay rent $550 here. And cable and phone bill and my car payment and my medicine and my food. All that expense, gas expense, everything. The money that Lippor pays us is not enough. . . . You calculate everything, my money is not enough. My groceries, and my gas, my car. And my tablets and medicine. Not enough! With higher co-pays and limited time, some workers report missing routine preventative care such as regular dental cleanings, vision tests, screenings, and treatment for the minor and chronic injuries that are so common in their jobs. Although they enjoy the benefits of living in a country with universal health care—and even though they work in hospitals—they no longer have access to the health care they need.

A Lack of Savings Low wages make it all but impossible for support workers to save money for the future. “How much you make right now, that’s what you spend now. There is no savings. There is nothing to look forward to. You just keep on working just to survive,” Daisy Utak says. Despite sharing a two-bedroom basement suite with her parents, Anna Balil, a twenty-four-year-old Indian housekeeper, says, “We can’t save anything. All of the money, whatever I earn and my father earns, it all goes to our

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household payments, paying rent, or my mom’s medications—stuff like that. Our bills like phone and stuff like that, whenever we pay it all goes. We can’t save anything.” The loss of job-based benefits after outsourcing hit support workers especially hard. While they once enjoyed perks comparable to those offered to doctors, nurses, and other health care professionals, now they basically receive only the minimum statutory benefits required by the British Columbia labor laws.11 Frederico Hilaga, hospital cook, says, “I was looking forward to the pension plan that we used to have with HEU, but now it’s gone.” At the same time, their low wages make it almost impossible to save independently for retirement. Catherine Ellis says, “I’m going to be fifty this year and I’ve got another, maybe fifteen years, and no pension, no future. So that’s where my thinking’s at most times.” Support workers are now a part of the growing group of service-sector workers who lack pension benefits. Where will they go when their cleaning days are over? There aren’t enough Walmart greeter jobs to go around. Or maybe they can move in with their working-age children and provide free child care in exchange for room and board. Now that their pension benefits have essentially been eliminated, support workers’ only option is to save for their own retirements. For most workers, this is simply not possible. Grace Caabay is about to retire. Like all other Canadian workers, she has been paying into the Canadian Pension Plan (CPP) her entire working life, and next year when she turns sixty-five years old, she will receive a few hundred dollars each month from the Canadian government.12 After sixteen years working at the hospital, the only support she can look forward to after retirement is a weekly check for a little over $250. Along with many other support workers rapidly advancing toward retirement age, she wonders how she will survive when she can no longer work. “So how can I live for a thousand [dollars] a month? I mean I have my credit card. I don’t know. Maybe I still work,” she says. Without pension benefits, or income to save, many of these workers will be forced to live out the rest of their lives in or near poverty when they retire, despite decades of hard and dangerous work cleaning hospitals and serving patients.13 After two hard-fought rounds of contract negotiations between the Hospital Employees’ Union, which represents these workers, and the private contractors over six years, the new collective agreement includes some improvements to jobbased benefits for support workers. For example, the new extended health plan includes reduced co-pays and deductibles for prescriptions and other health services. Workers also now receive a small discount on their transit passes. Despite these concrete gains, the benefits still fall far short of pre-outsourcing levels. Some of their benefits also exist only in theory. Employers have been making use of exemptions in the contract to prevent employees from taking advantage of benefits to which they are supposedly entitled. The contractors,

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for example, tell workers they cannot take their mandated time off because the company cannot find a casual employee to temporarily replace them. Cook Frederico Hilaga explains, “Even when you want to take sick leave or vacation, you cannot get it because there’s a special thing in the contract: ‘due to operational performance.’ We don’t understand that, because they’re saying you can’t get someone to replace you, that’s why we can’t let you go.”

No Vacation It is widely recognized that workers need at least some time off work over the course of the year. Taking vacations improves employee mental health and well-being.14 But even if support workers could find a little time off, they generally lack the resources to get very far. For many immigrant workers, lack of vacations means separation from family and friends in their country of origin for years at a time. It has been over ten years since Amita Pamintuan, housekeeper, last had a vacation, when she visited family in the Philippines. “I enjoyed it with my mom and my sisters and nephews and nieces,” she reminisces. Suzanna Lopez, dietary aide, explains that her most recent vacation was not exactly a relaxing resort trip. “I went home when my mom died [in November 2003], so that’s the last time I went back to the Philippines,” she says. Long-term separation from family is especially painful for workers who are supporting children who live abroad. Daisy Utak last saw her two daughters seven years ago when they were nine and eleven years old. She has missed out on many critical years of her children’s lives. Workers often lament that they can’t afford to take even low-cost vacations, such as camping or hiking. Some wish that they could explore their new country and experience “traditional” Canadian family vacations. Juan Laguatan, a single father with two teenagers, immigrated to Canada four years ago for its “greener pastures.” As he explains, “I read about Canada before, its good governments, community, natural environment, and things like that. It sounded really inviting.” He was disappointed to find that “living in Canada is tough. It’s really, really tough. I underestimated that.” When asked about his last vacation, he replied, “Oh God, I don’t have vacation.” Next year, he hopes to go to the Philippines. “I haven’t been back home yet. We have never been back to the Philippines, so maybe I could take a trip and see my mom.” He also hopes in the next ten years, he will get to see more of Canada’s natural wonders. Because of this job . . . I can only see this place in the newspapers and magazines. You don’t have money. Some people want to go for a roast beef or something like that, but you don’t have much money to spend for it, so

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you have to smell it, and go for the potato chips. The same thing. You have to smell that Grouse Mountain, good natural resources. . . . I wish I could. I have been in Canada for three and a half years, and I have never been in this Grouse Mountain here. I’ve never been to Capilano, strolling around the park—I haven’t experienced that yet. You’ve got a beautiful surroundings, natural resources, and I want to see them, but my kind of work can only see them in the books or newspapers but not in reality. I can smell it! Others pined longingly when asked about their last vacation, often a distant memory. Lucy Cusito, housekeeper, has not had a vacation since arriving in Canada. “I never have vacation, just work, work, work,” she says. The former teacher hopes to travel in the future. “I want to go to other countries also, have a vacation like that. I want to see my relatives that in Mexico, Hawaii, and Australia. We are only receiving $1,000 a month. How much food, rent? Me, I’m paying [alone] my medicine, $200 something a month.”

Outsourced Workers, Broken Families Outsourcing has torn apart families in many different ways. For one thing, hospital workers often find themselves completely at the mercy of the moods and disposition of their supervisors; and the supervisors aren’t always interested in family issues. Lisa Dodson’s The Moral Underground highlights the ways some middle-class professionals and managers in the United States are bending or even breaking the rules to help their struggling employees get by. With the right support from above, some workers can just about manage to juggle their work and family responsibilities. Gaya Johl, a mother of two children, describes a moment of compassion: Two months ago, my son was so sick at night. The next day, before I go to work, I talk to him and I say, “I don’t know if I’m going to work or not,” and he says “You go ahead.” But when I go in there and she [my supervisor] saw my face and she says, “Is something wrong with you?” And I say, “Yes my son, I don’t know what happened to him last night, he’s sick.” And she says, “Right now, you go home.” She said it right away. Then I feel she knows the problem is that my kid’s alone at home. She helped me that day. I never forget for that. Unfortunately, such understanding doesn’t seem to be the norm. In my conversations with support workers, I heard many stories about rigid rules and uncaring managers. Even Johl says that she would be reluctant to take a day off work if she

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were sick or hurt because she would be afraid of her supervisor’s reaction. Renata Patel says that she rarely gets a sense of cooperation or understanding from her supervisors. “If we have an emergency case in our family, [the managers] say, ‘Oh, you can work,’ ” she says. Many support workers say that their supervisors are reluctant to give them time off to deal with family crises. In fact, they are frequently rude or dismissive of their requests. Freda Bansal, housekeeper, says she couldn’t get any time off when her grandson was sick in the hospital and her daughter was unable to visit him; Bansal says she does not like asking for time off because the managers are always especially hard on her when she comes back. Juan Laguatan complains that his hospital and handyman jobs together leave him with little time to spend with his two children: Most of the time they are being neglected. I can see that, but you have no choice sometimes. Have no choice. I do some scheduling to the children, each have to do this and do that, but they are children. They need you sometimes. So you are neglectful with your family, as well with the other people. . . . I need to spend some time with the children. The implication is not good. Sometimes I can feel they need me, they needed your attention, they needed your advice. In some cases, the distance between workers and their children can be measured in thousands of miles. Kerry Lyons, dietary aide, sent her four-year-old son back to the Philippines to be raised by his grandparents. “I sent him back because I’m working a couple of jobs, plus I’m studying,” she says. “It’s better for him to stay with my parents. I’ve been away from him for three years.” When asked how she feels about having her parents raise him in the Philippines, she replies, “It’s hard, it’s really, really sad, and, it’s very sad. I’m planning to go back, actually this December, but you know, I have to work.” Lyons says that weekly phone calls with her son are a source of strength. “It’s like a battery,” she says. “If I hear his voice, I’ll be very, very happy. But if not, I’ll be really, really sad, and not focused in my job. So it’s like a therapy to me, talking to him.” She hopes to eventually bring her son to live with her again in Vancouver. “As soon as I finish my studies, probably I can get a nice job and they pay me a nice wage,” she says. “Probably, hopefully, soon.” Despite the distance between them, Lyons tries to do what she can to support her son. “I send money back home once in a while. Brother and parents . . . and there’s a lot of them actually [laughs]. And four nephews, studying, helping them with their studies, that’s why I have to send money,” she says. She wishes that she

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could afford to work only five days per week instead of seven. But with so much at stake, she feels that she can’t miss a single opportunity to make money.

Far-Flung Obligations Many hospital support workers have family obligations that span the globe. Jasmine Chaudry, housekeeper, and her husband send money back to Sri Lanka to help support eleven members of their extended family. Penny Bagga, also a housekeeper, sends money back to her fifty-three-year-old brother in Fiji to help pay for the education of her twenty-one-year-old niece and thirteen-year-old nephew. Given the high levels of need, support workers have a strong incentive to send money to their families, even if they have to work several jobs to do so. Diana Mamaril, housekeeper, is mother of a three-year-old. Both she and her husband help support their elderly parents in the Philippines. Her current credit card bills top $25,000, and her husband owes another $5,000—but they can’t stop wiring money back home. Some support workers have to regularly return to their home countries to care for ailing parents or other relatives. Grace Caabay took care of her ill, elderly parents during a recent trip to the Philippines. “They’re ninety years old, always in the hospital,” she says. “Sometimes I think about my life. When can I have a vacation?” Ida Bates, dietary aide, regularly sends money to her niece in the Philippines. “Now even if I don’t have money, I send money,” she says. “My priority is my immediate relatives.” On her last vacation, she traveled back to the Philippines to celebrate her father’s eighty-fourth birthday.15 As she recalls, it was a bittersweet scene: “My mom died fourteen years ago, so we spoil our dad and our dad expect us to, it’s a Filipino tradition. The parents expect the children to comfort them when they’re old, like babies. I was the one who spend for my dad’s birthday party and we spend a lot because he expected to have a good party, because I was there. It was a happy, happy, happy moment. But after coming from there I was sad, because I wish I could stay longer but I have to come back to my job. Because I’m only allowed two weeks paid vacation, I cannot afford to extend more or else I don’t have money.” The prospect of making enough money to share the wealth back home was a big reason many workers came to Canada in the first place. Amita Pamintuan lives alone in a studio apartment that she rents for $550 per month. By saving as much as she possibly can, she manages to send a little money back to the Philippines to help support her mother. She sometimes questions her decision to leave

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home: “Sometimes I think ‘Oh my god, why am I here in Vancouver? I should be with my family in the Philippines doing this and doing that, enjoying life.’ But here, no, you cannot enjoy your life here. You have to work, work, work, work. Because if you don’t work, you don’t pay your rent.”

Caring for Parents Others have heavy care demands at home. Freda Bansal, a mother of three adult children, just made the agonizing decision to put her mother in an assisted living home because she felt she did not have time to take care of her: “It was just too much for me to handle. I work full time here and then I go to work two days a week, I work at [a major supermarket chain]. So seven days [a week], I’m out of the house, and then in the evening I have to attend to the housework, and the cooking, and taking care of her. She is quite old, so now I have to put her in assisted living.” As is often the case, Bansal’s family obligations span generations. “I have no time for my grandkids,” she says. “I would love to spend nice day, go home, take them to a park, go do something. But I’m so tired, I just want to sit down.” Amarita Kohli, dietary aide, quit one of her three part-time jobs to take care of her elderly mother-in-law who lives with Kohli and her family. “Sometimes my mother-in-law doesn’t want me to go to work, so that’s why I decided to quit my one job,” she says. “Because she’s old now, sometimes she needs me.”

Parenting on the Night Shift Beyond low wages and weak benefits, other dimensions of hospital support work make these jobs less than family friendly. Hospitals don’t shut down at night, which means many support workers end up working nonstandard hours. Some work through the night. Others work from early morning to early afternoon or from mid-afternoon until midnight. Anyone who has been a patient in a hospital for more than a few days can see the effects of long shifts on workers; upbeat and positive at the start of the shift, they are exhausted and more likely to make mistakes after long hours on the job. Research shows there are serious negative effects of exhaustion and sleep deprivation on performance, whether you’re a long-haul trucker or an ER nurse.16 Other studies point to the negative consequences of chronic sleep deprivation. Those who sleep less than six hours per night are at much higher risk of heart problems, diabetes, obesity, and early death. Thousands of medical errors have been attributed specifically to exhaustion among residents in hospitals, leading to new guidelines limiting shifts for first-year residents or interns to sixteen

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hours.17 What has not been measured are the number of patients needlessly put at risk by overtired nurses and others working in hospitals. Nevertheless, some support workers wish they had more hours, not less. As a casual on-call employee, Kerry Lyons has to sit by the phone at home waiting in the hopes that she is called to come in. “That’s why I can’t go out,” she says. “If I go out and they phone me then I’ll lose my seventy bucks. So I just stay at home and wait for their call. I have zero life.” If socializing at odd hours is a challenge, parenting is orders of magnitude more difficult. Gaya Johl works from Wednesday through Sunday, from 10:15 a.m. to 6:15 p.m., in the kitchen at Alderwood Hospital. She says her work schedule makes it “very difficult” for her to spend time with her children: “Because my kids are off Saturday and Sunday [from school], they want me at home. But I start on Saturday and I can’t stay with them. I very [rarely] call in sick because I have only six days for the year. Then we don’t have the time to sit together. When I [get home from work], it’s almost dinnertime, and I’m just running around. First, I finish my work, and then I am looking for whatever I can cook for my kids. So then I feel so bad I don’t give enough time for my kids.” Penny Bagga says the graveyard shift makes it nearly impossible for her to take care of her kids. As she explains, “I have no family life. I choose this job because I need money. My husband, he works six days per work, and he gets Sunday off and I’m working Sunday. Sometimes I don’t even have time to spend with my husband. . . . So my kids are complaining ‘Mommy, get a decent job.’ ” Nonstandard work shifts are particularly hard on families with younger children. Because they work long hours on the weekends or at night, hospital support workers often miss important family occasions or events. Doria Markopoulos, dietary aide, relates, “Next Sunday, I have a funeral service, a close friend, and I don’t know if I’m going to have it off. So sometimes it is very difficult. My kids ask, ‘Mom are you working Christmas?’ I remember for eighteen years, I’m working and maybe I have two Christmases off, and even now my husband cooks the turkey. I’m lucky, some people have two or three jobs.” Despite the low wages and poor working conditions after their jobs were contracted out, many support workers still chose to reapply for their own jobs rather than face unemployment or apply for other low-wage service-sector jobs. In the new economy, new hires in low-wage service sector jobs often begin “on probation.” They may have to work for several years to secure full-time hours or a decent schedule. The last hired are often the first fired. Sometimes they even begin as casual employees, without a regular shift and with only part-time, unstable work hours. These disincentives made some workers hesitant to leave hospital support work and start all over again in a different field. They end up trapped, working extremely hard for less than a living wage.

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In so many ways, the outsourcing of support jobs has set up these workers to fail—financially, emotionally, and physically. And if they fail, the question must be asked: What does that mean for the rest of us?

Low-Road Jobs Hurt Families and Communities Healthy families, motivated children, safe communities stand on a bedrock of gainful employment. —Katherine S. Newman, No Shame in My Game18

When you cut the wages and benefits of a large group of already marginalized workers, the impact ripples throughout families and, eventually, whole communities. The outsourcing of hospital support workers in Vancouver and elsewhere has put individuals and families in peril. In Vancouver, the poorest neighborhoods suddenly saw some new faces, and workers forfeited both the time and the resources needed to raise their children or stay involved in their communities.

Unsafe at Home Low-road employment has plunged many hospital workers into crime-ridden neighborhoods where fear and distrust overwhelm any sense of community. Many feel isolated and even fearful.19 Juanita Romero, housekeeper, does not feel safe in her neighborhood. She explains, “At night time, I walk so fast. . . . I watch . . . behind me because I’m walking from there, and it’s very scary because people are walking.” Francine Rankin, housekeeper, says that in her neighborhood “Crime, oh god yeah. My car has been—tried to break into it twice. I’ve had it keyed. I’ve had it walked on. Sirens going every night. A woman was raped a block away from me. Yeah, definitely, all the good stuff.” Sam King, a forty-eight-year-old hospital cook, lives in a multicultural co-operative (co-op) housing development next to the rugged downtown neighborhood. He said his neighbors run the gamut from security guards to housecleaners. “We have our own cameras, security cameras,” he says. “We have a volunteer watch, just basically [to keep out] the homeless. I feel sorry for them, but they’re bringing drug problems into our neighborhood.” Although he feels safe during the day, he won’t go out at night alone. Last year, someone stole all his Christmas decorations. “That was devastating for me because I had something from my great, great grandmother [taken],” he says.

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King sends his eleven-year-old son to a local public school that’s rife with social problems. “The location scares me, because it’s in the downtown eastside,” he says. “A few of us, the parents, have had to chase the dealers or addicts off the [school] property. It gets rough. I’d like to warn the new people who are just moving in right now. They don’t know how close it is to the highest crime area in Canada.”

Increasing Social Isolation Outsourcing has strained the ties between support workers and their safety net of family and friends. With limited time and even more limited finances, workers often feel unable to help their families, even in times of crisis. Outsourcing has been hard on marriages, too as Frederico Hilaga relates, “It’s really affecting our social life because sometimes we’re so tired, and I can’t even have a chat with my wife. She also works ten to twelve hours a day. It’s getting to the point that we’re not getting any good communication. So as of now, we’re just looking for our vacation so we can get away, out of this mess, just to relax. It really affects our life.” Jasmine Chaudry and her husband trade off child-care responsibilities for their three children. This arrangement exacts a personal cost; each parent returns home for a solo run at the “second shift” of taking care of the children and home. To put it mildly, it’s not the ideal arrangement for marital relations, either. As hard as life is for her, Chaudry says she cannot imagine how working single parents manage. The husband of Imee Wenceslao, dietary aide, works in the United States. She visited him on her last vacation for all of five days. She recently had to postpone her next visit to her family back in the Philippines for at least six months for financial reasons. “I want to see my mom,” she says. “It’s now five years and three months. That’s a long time, I haven’t seen her. I’ve just seen her on the computer, on the Internet, and that’s it.” Even though she’s single and childless, Suzanna Lopez says she doesn’t have time to do much outside of working: “Nothing. I have to work. I have part-time job on Wednesday and Thursday, on my day off, and after that I have to rush, I have to prepare dinner, clean the house, do laundry, so there’s no social life. Sometimes in the church, we socialize after mass, we go downstairs for tea and coffee and we meet other people, other Filipinos, that’s it.” Renata Patel was disappointed that her manager would not allow her to switch to a Monday to Friday work schedule instead of her current Sunday though Thursday work week: “My religion is Christian, and I miss Sunday services. I want to go every Sunday to my church. I miss big things. I miss my church service. Church is important. But my manager, he didn’t give a Sunday off. And I can’t

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help it. He didn’t listen. And that’s why I miss my church. That is very important thing for my life.” Gaya Johl said she would love to get more involved in social groups, clubs, or her children’s school. “I want that, I love that, but I have no time to do that because I have two days off, Thursday, Friday, and then I clean up my house, laundry. And then I try to make the lunch for my kids. I have no time to go out,” she says. While more economically advantaged or professional parents can afford to outsource some of these responsibilities, parents in low-income households, instead, more frequently turn to relational resources, such as extended family members, to provide care work. Time is a precious resource in the new economy. Being able to predict and regulate your schedule is an important foundation for greater involvement in social and community networks and organization. Through a combination of low wages, work intensification, and shifting schedules, outsourced workers rarely achieve healthy, engaged, and balanced lives. The consequences of declining levels of social connection, capital, and trust are most severe for lower-income families in high-poverty neighborhoods. As highlighted by the classic research of Carol Stack, anthropologist, in All Our Kin the resources and support from neighbors are particularly important for the well-being of those who live in low-income urban communities. Because people living in these kinds of neighborhoods have limited access to resources, they depend on community social capital to make ends meet.20 Sociologists have found that social cohesion and community efficacy are crucial to the well-being of urban neighborhoods. For example, in Heat Wave, Eric Klinenberg explains that access to neighborhood social capital largely determines whether vulnerable elderly people will survive a heat wave. In a similar vein, Robert Sampson, Steven Raudenbush, and Felton Earls argue that lower levels of community cohesion result in a higher rate of violent crime in neighborhoods.21 William J. Wilson, sociologist, has pointed to the central role of joblessness in explaining the high levels of social dislocation and lack of community efficacy in urban poor neighborhoods.22 Employment, even in low-road jobs, has generally been portrayed as a positive factor for creating community efficacy and well-being.23 Yet not all kinds of employment have an equal effect on community well-being. While higher levels of employment may certainly be better for individuals and communities, the characteristics of certain jobs can also harm the community by preventing workers from having enough income to adequately maintain their homes. Low wages and nonexistent benefits might also require workers to combine multiple jobs to make ends meet, thus creating barriers for people to become involved in community institutions, such as their children’s schools, that are so central for building community social cohesion.

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The economic shift toward multinational corporate employers and franchise capitalism threatens the foundations of local communities. While these employers extract profits and redistribute them to global elites and shareholders, employees are faced with low wages, weak or nonexistent benefits, and poor working conditions.24 Beyond their environmentally unsustainable and destructive impact, these corporations erode community through the kinds of jobs they offer. So what can be done to improve the experiences and quality of life of these and millions of outsourced service-sector support workers?

Fighting the Rising Tide of Low-Wage Service Jobs As bad as things are, workers know that their plight would be even worse without the unions on their side. Doria Markopoulos says that, “without the union, we’re going to only make $10.80 [per hour]. . . . With the union, now we’re taking $13.05 [per hour].”25 Amarita Kohli says that prior to privatization the union helped her get another health care job when her previous employer closed down. And when the workforce was privatized, the union helped her keep her job, albeit at a substantially reduced wage. “It was only $10 dollars starting, but doesn’t matter,” she says, “because it’s hard to find a job. So I was lucky.” Unions play a vital role for improving the job security, wages, and benefits of lower-tier service-sector workers in industrialized countries.26 In the United States, increasing poverty and inequality can be directly linked to declining unionization levels.27 As Ruth Milkman, sociologist, argues in L.A. Story, “Not only do unionized workers earn, on average, substantially higher wages than their nonunion counterparts, but non-union employers have become less and less likely to match the level of union wages, as many had done in the 1950s and 1960s, as the threat (real or imagined) of unionization has receded. De-unionization has also undermined job security and facilitated the casualization of employment arrangements.”28 In the case of outsourced hospital support workers in British Columbia, the HEU has successfully improved the wages, benefits, and workplace conditions since outsourcing. When these jobs were contracted out in late 2003, the HEU organized a health care strike that generated a massive, provincewide sympathetic action by unionized workers across many sectors. In fact, the decision to outsource these jobs and implement across-the-board wage cuts for health care workers almost resulted in a general strike in the province, averted only by lastminute concessions by the provincial government.

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The HEU has continued to campaign to improve the wages, benefits, and working conditions of these support workers. The union also helped organize a living-wage campaign in Vancouver and has mobilized members to become engaged politically.29 Eve Nicdao, housekeeper, says her union “made a big difference with the bargaining. They helped us get a better wage, even though we were not able to get everything, but our medical benefits are 100 percent and before it wasn’t.” Lily Oracio says that “the union gives you job security, and, yeah, the job security’s number one.” In some cases, the union helped workers access their contractual benefits, including vacations. In other cases, it helped employees take action against unfair supervisors. “If we have a problem with the management, we can talk to them,” says Suzanna Lopez. “The [union shop] steward is helping us settle when we disagree with the management.” The role of the union as an advocate for vulnerable workers is clearly important, perhaps even more so for outsourced workers who can no longer access normal employee channels within the health care system. Lopez wishes the union was even tougher with managers. “Sometimes we need more aggressive people to talk to the management, especially the upper manager,” she says. “She’s really hard to deal with, so we need more people who really stand for us.” Worker-friendly labor policies improve lives of workers and their families. Policies mandating a decent minimum wage, benefits, and safe working conditions are necessary to protect the interests of vulnerable workers. Yet it is also important that these worker-friendly policies be actually enforced. Unions provide workers the resources they frequently need to actualize their workplace rights. The advocacy role played by unions is particularly important for workers who lack the information and resources they need to stand up for their own rights. Union representation helps defend against “bad apple” employers and protect vulnerable workers. In the case of the HEU, the role of the union clearly goes beyond the traditional model of business unionism to embrace social movement unionism.30 Not only does the HEU provide resources for workers to become stronger advocates in their workplace, it empowers them to become more active in their communities and in the political sphere. The union has introduced workers to politically active leaders and employee advocates. Meeting these leaders and hearing their stories inspires workers and gives them greater confidence to advocate for their rights both in the workplace and in their daily lives. More of this sort of social movement unionism is needed in the United States, the United Kingdom, and Canada.

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Some support workers say they learned leadership and advocacy skills at union training sessions. Notably, women from other countries learned how women in Canada had organized and lobbied for concrete victories in the political and policy arena. For many support workers, becoming involved in the union inspired them and gave them a better sense of the role of activism in democratic society. Support workers were also empowered in the workplace. Daisy Utak says that the union “taught me about my rights to be a worker and they taught me how to read the collective agreement, and that’s what I shared with my co-workers.” She went on to become chief shop steward of her local. “If my co-workers have problems from work, they come to me and we talk about it, and then I will call the union and talk to them about it. And then they will give me some ideas of how to deal with it,” she says.

7 CLEANING UP

Fighting antibiotic resistance is like wrestling Kali, the many-armed Hindu goddess of life and death. It is not one problem but many. —Madeline Drexler, Emerging Epidemics

Florence Nightingale’s 150-year-old insight has lost none of its urgency: Poor hospital sanitation is not just an enemy of good healing, it can be a leading cause of disease and death. —Nancy Pollak, Falling Standards, Rising Risks

In the early afternoon of April 29, 2007, after my spouse went through thirty-six hours of labor and a caesarean birth, I held our beautiful baby girl in my arms. As I looked down at this little bundle swaddled in a yellow towel, I realized that she was more important to me than anything in the world. Looking back, I think about all the people behind the scenes. Somebody had to clean that room—the very first room that my daughter would ever see. Thousands of nervous, excited dads have stood in my exact place in that recovery room, and thousands more will follow. The labor room, the OR, the recovery room, the baby suite, the halls—they were all part of my daughter’s entry into the world. This hospital is not a hotel or a restaurant or a conference center. It’s a place where people are born, where people die, and where people recover from serious illness and trauma. The people here work with blood, pus, vomit, and mucous. Hotel workers may have to clean up behind the occasional partying rock star, but they don’t have to push their mops past terminal cancer patients taking their final breaths or clean up blood splatters after an unsuccessful triple bypass. Unbelievably, the cleaning, maintenance, food service, and many other support staff in this hospital are now paid far less than a housekeeper at a typical major downtown hotel chain. And they don’t get tips, either. Hotels can lose a star from their rating if cleanliness suffers. Hospitals can lose patients. The almost overnight decision to outsource hospital support workers may have saved a few dollars in the short term, but in the long run, the move raised the risk of outbreaks and put workers in peril. 105

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Despite the critically important work they do, hospital support workers are a devalued and nearly invisible group. Movies such as Dirty Pretty Things and books such as Nickel and Dimed have increased public awareness of hotel housekeepers, but people doing similar work in hospitals still toil in obscurity. Doctors and nurses—already highly valued and respected members of the community— are glorified in sensational TV shows such as ER and House. Nobody’s going to make a show about the people in the health care system who clean, cook, prep rooms, serve food, empty hypodermic disposal collection boxes, wipe up blood, and make beds. In retrospect, support services were too important—too critical to the hospital’s core mission—to be outsourced. Instead of looking for ways to save money, hospitals should be striving to improve quality. As a key component of reform, cleaners and other support workers in the hospital should be treated and valued as important parts of the health care team and not as merely auxiliary laborers. Training, adequate staffing levels, decent pay, protective gear—the investment in workers would pay off in cleaner hospitals and safer communities. As I write this, I’m looking forward to reentering the hospital for the birth of our second child. While I’m excited, I’m also anxious. My many conversations with hospital workers have planted new fears and misgivings. The hospital where she will be delivered has some of the best doctors and medical staff in western Canada. But I worry. My spouse may very well need another cesarean section. If that happens, I now know that there’s a 1 in 5 chance of complications, such as infection.1 I look forward to leaving the hospital as quickly as possible, healthy baby in arms, and I hope to not to have to return for a long time. We know that it is possible to do better. Countries such as the Netherlands and Norway have done an extraordinary job of keeping rates of hospital-acquired infections extremely low. They have been proactive about hospital hygiene and other infection-control approaches and have largely avoided outsourcing hospital support services. The outsourcing of hospital support workers in Canada, the United States, and elsewhere has unleashed a cascade of negative consequences that go far beyond the health care system. Getting serious about health outcomes requires more than just hospital-based reforms or medical innovation. Growing evidence suggests that the explosion in screening and expensive lab tests isn’t necessarily resulting in better health outcomes;2 what is needed is a return to basic health measures to keep people healthy and out of the hospital. That means focusing on preventive health care and public welfare. Fundamentally, it also means challenging the broader political ideology that underlies the declining support for public services.

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Reducing Hospital-Acquired Infections Hospital-acquired infections are a full-blown health crisis and should be treated as such. We don’t need panic in the streets—or in the emergency room—but we do need a concerted, systemwide effort to stem the infections. It’s estimated that at least 30–50 percent of hospital-acquired infections could be prevented through improved infection-control procedures, saving thousands of lives annually in Canada alone.3 Unfortunately, the development of new antibiotics to vanquish the emerging resistant infections does not appear to be on the nearterm horizon, despite initiatives by the Infectious Diseases Society which calls for the development of ten new antibacterial drugs by 2020 (to avoid “impending disaster”).4 In step with this essential and urgent attempt to stay a step ahead of microbial evolution, we must do what we can right now to reduce the transmission of infectious pathogens through investments in prevention and infection control. While there are upfront costs to effective infection control, the savings in lives and health care costs would be tremendous. Infected patients are expensive patients. They need high-end antibiotics and long stays. They become bedblockers, preventing others from getting the care they need. Louisa Appleton, an infection-control practitioner at a Vancouver hospital, sees trouble ahead if hospitals can’t get a handle on infections: “We are not going to have the capacity we need to take care of patients,” she says. “We already see the delay now with patients not being able to get up to units because they don’t have private rooms.” Of course, it would take a monumental effort on many levels to significantly reduce health care–associated infections.5 The Canadian Union of Public Employees recommends straightforward commonsense steps that would certainly move the battle against health care–associated infections right direction. The list includes “Well-resourced, well-trained, and stable in-house healthcare teams attacking all of the links of transmission; sufficient beds, equipment and staff to achieve best practice occupancy rates; modern high-quality infrastructure and equipment, and standardized procedures, monitoring and public reporting.”6 Germs aren’t spread randomly throughout hospitals. When experts take a closer look, they see particular hot spots where outbreaks ignite. It’s estimated that 40 percent of hospital-acquired infections—adding up to as many as 28,000 deaths in the United States alone—result from contaminated catheters. Dr. Peter J. Pronovost at the Johns Hopkins University developed a simple checklist protocol to stop catheter infections that, in his words, “succeeded beyond anyone’s dreams.” Tests in 108 intensive care hospitals in Michigan showed that the new approach virtually eliminated catheter infections.7

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The life-saving protocol includes several steps: 1. 2. 3. 4. 5. 6. 7.

Wash hands with soap. Clean the patient’s skin with chlorhexidine antiseptic. Put sterile drapes over the entire patient. Wear a sterile mask, hat, gown, and gloves. Put a sterile dressing over the catheter site. Avoid the femoral site, when possible. Avoid unnecessary catheters.8

It cost about $500,000 to mandate these steps in every hospital during the trial run, but the cost savings were estimated at nearly $200 million. Thousands of lives were likely spared, and there’s no way to put a price on the savings in pain and suffering.9 The success of this experiment has generated intense national and international interest.10 As of 2009, approximately 10 percent of U.S. hospitals used or were implementing checklists, joining about 2,000 hospitals globally.11 In Canada, for example, Ontario recently decided to adopt its own version of a checklist to reduce infections.12 If many more hospitals adopted checklists, thousands of lives could be saved. The reforms don’t always produce immediate results. In the province of Quebec, it took five years of hard work to reduce C. difficile rates to pre-epidemic levels after an outbreak.13 But the eventual payoff was huge—as a direct result of reforms, overall infection rates and MRSA infection rates dropped by between 40 and 60 percent in the province.14 Similarly, by setting targets, improving monitoring, and dedicating resources to implementing reforms, the United Kingdom has been able to achieve a 49 percent reduction in MRSA infections from 2003–2004 to 2008.15 Prior to that, the infection risk had become so serious in UK hospitals that patients and relatives were bringing their own “personal protection packs”—including silver-threaded pajamas—with the (impossible) goal of creating a “personal protection zone” against germs.16 A multipronged approach is key. Veronica Sendal, an epidemiologist who consults in hospitals and health care systems in the United States, explains how a New York State Department of Health program cut infection rates in participating hospitals by 20 percent. For one thing, the hospitals started isolating patients soon as they suspected a case of C. difficile instead of waiting for test results to confirm the infection. She continues, “We eliminated the use of electronic rectal thermometers that go from patient to patient. If there are electronic thermometers used—or rather if rectal temps are necessary—patients would be given their own individual disposable thermometer or their own thermometer to be used while they are in the facility. We developed signs that were shared by the various facilities for identifying patients with C. difficile and they also came up with a

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hierarchy that we would ideally put patients in a private room.” Significantly, they also developed a new housekeeping checklist. Among other things, it mandated the use of chlorine bleach in the rooms of patients with C. difficile. Sendal sees much room for further progress: “I do not think the United States, Canada or anywhere else has sufficiently invested in the surveillance, prevention and control of HAIs [hospital-acquired infections],” she says. Her vision for cleaner, safer hospitals addresses many of the issues that I have discussed throughout this book: adequate staffing levels; equipment that can be safely and reliably cleaned; smarter use of antibiotics; and proper training in infection control for all health care professionals, cleaners included. The first step, Sendal says, is generating the political will and securing resources to implement much needed reforms.

Increasing Monitoring of Infections Hospitals need to be accountable for infections. For starters, they must be required to report all infections that occur within their doors.17 Many U.S. states and most Canadian provinces—but not all—now require the public reporting of hospital infection data.18 Opponents of mandatory reporting argue that some hospitals, such as those with trauma centers and burn units, will be inherently disadvantaged because their patients are especially vulnerable to germs.19 But more widespread monitoring and public reporting will allow the identification of problematic hot spots, generate greater awareness of the scale of the problem, and, in the best-case scenario, identify policies and reforms that actually work to reduce infection rates.20 Rigorous monitoring and reporting of infection rates in some Canadian provinces—including Quebec and Ontario—have shined a spotlight on the high costs of hospital-acquired infections and spurred new action toward infection control.21 All Canadian hospitals and nursing homes now must report their rates of MRSA, C. difficile, and VRE infections to become accredited.22 It’s unrealistic to expect reforms to completely eliminate all health care– associated infections. Yet setting targets, improving monitoring, and putting the right resources in the right places can result in dramatic reductions over a period of several years. There are many reasons to improve hospital infection control practices. From a hard-headed policy analysis perspective, the cost of preventing these infections pales in comparison with the costs of treatment and the lost productivity of infected patients.23 But this simple cost-benefit analysis overlooks the human suffering that comes with every infection. It also ignores the unfortunate tendency of health care administrators to focus on short-term costs without considering the

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bigger picture.24 Although infection control is not cheap, the benefits easily outweigh the costs just about any way you look at it.25 There are several basic approaches to reform. While some programs provide incentives such as monetary rewards for “good behavior,” others use a more fearbased or shaming approach. Dr. Robert Stanwick, chief medical officer for the Vancouver Island Health Authority, recommends that health care workers be scared into compliance with infection-control practices to reduce transmission. The Safety First program he helped develop stresses to workers that they could bring germs home to their families if they aren’t germ-conscious at work.26 While a fear-based approach may make workers more aware of germ control, it doesn’t provide important resources—such as better training or better equipment—to help turn awareness into action. Many attempts to modify health care worker behavior ultimately fail because they ignore the structural realities of the hospital hierarchy. They also ignore the challenges—high stress, overwork, long shifts, and understaffing—that nearly all workers in the health care system experience. The most effective reforms have been based on “positive deviance” approaches, including identifying outliers within an organization as models to help creatively address challenges in the context of restraints and encourage positive individual behavior change to enact reform and ultimately reduce hospitalacquired infection rates.27

Cleaner Hands, Cleaner Hospitals When it comes to germ control, some hospital workers need to start at square one. As Michael Gardam, director of infection prevention control, University Health Network in Toronto, said in a Globe & Mail newspaper op-ed, “strategies to prevent the spread of infection—such as hand-washing, good housekeeping, and appropriate antibiotic use—are so basic and, frankly, obvious that I think we assume they are being done. Well, they aren’t: It’s time to wake up and smell the disinfectant.”28 One positive reinforcement strategy adopted by Gardam is to provide $2 Tim Horton’s gift certificates for those health care workers “caught” washing their hands at three Toronto-area hospitals. “Hand hygiene is a crucial and obvious step to reducing infections, yet prodding those who provide care to scrub up has been maddeningly difficult,” he wrote. “Only 40 per cent of Canadian health-care workers wash their hands properly.” Initiatives to improve hand-washing are becoming widespread. Gardam adopted his approach from Cedars-Sinai Medical Center in Los Angeles.29 These hand-cleaning incentives are a small step in the right direction. Even Gardam realizes their limitations. As he notes, “hospitals can improve hand washing

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routines, but that will have little impact unless accompanied by other measures, such as enhanced institutional cleaning regimes.”30 Health care workers are also more likely to disinfect their hands regularly if they work in an environment where hospital hygiene is clearly a priority.31

The Limits of Hand-Washing: The Importance of Proper Cleaning If germ-ridden hands were the only source of infections, hand sanitizer alone could solve the problem. In the real world, germs can hide just about anywhere. Immunocompromised patients can become infected with MRSA from stirred up dust under beds.32 Even properly washed hands will quickly become contaminated in an unclean environment. Without proper cleaning and disinfection, these pathogens can survive for hours—or even days, weeks, or months—in hospital environments, posing an ongoing risk of new outbreaks.33 While hand-sanitizing campaigns are incredibly important for reducing hospital-acquired infections and improving patient safety, sometimes there is an incorrect sense that it is both the start and end of effective infection control in hospitals. Brian Johnson, a physician and professor of medicine in Vancouver, says that some hospitals focus almost exclusively on hand-washing when they should be looking at the bigger problem. “Their approach is very mechanical and doesn’t take into account the rich dynamic environment that a hospital actually is,” he says. “So until that is addressed I don’t see them necessarily making significant inroads.” Infection-control policies are truly put to the test when an outbreak occurs. Along with new precautions, isolations, and testing, hospitals will implement an intensive cleaning and disinfecting campaign soon after the discovery of an outbreak.34 Outbreaks also tend to inspire a lot of meetings where various stakeholders get together to talk about what went wrong, make accusations, and promise to do things better in the future.35 Once an outbreak is under control, complacency tends to set in and hospitals return to their “bad habits” until another crisis emerges. Implementing best practices and proactive reforms requires concerted commitment over the long term with regular monitoring, reporting, and constant efforts for improvement. Continuous professional development for cleaners and other support workers, including training based on the latest infection-control innovations, is one of the most important steps a health care system can take to slow the spread of infections. Cleaners in health care settings should receive extensive infectioncontrol training before beginning their jobs, and they should be required to regularly update their training throughout their employment.36

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In the United Kingdom, after two decades of cutbacks, privatization, and outsourcing, nurses reported that they felt constrained in their ability to directly control and improve cleaners’ performance.37 They have responded by officially reaching out to cleaning staff. Their new charter specifically states that “[nurses] will make sure they [cleaning staff] feel part of the ward team [and] all staff working in health care will receive education in infection control.”38 The success of this program has sparked interest in replicating a similar program of infectioncontrol nurses in Vancouver hospitals called Infection Prevention and Control (IPAC) Link Nurses to promote infection-control education and best practices. In a much more dramatic move, the governments of Scotland, Wales, and Northern Ireland decided to end outsourcing for hospital support workers and bring the jobs back in-house.39 Likewise, the head of the Center for Disease Control of Taiwan recommended bringing support services back in-house in the aftermath of the SARS outbreak in 2003.40 In all these cases, administrators have recognized the critical role of support workers for ensuring patient safety and the quality of patient care.

Investing in Cleanliness Growing public outrage at the shocking numbers of patients suffering—and even dying—from preventable hospital-acquired infections has begun to get the attention of policymakers. Individual states and accreditation bodies are requiring the collection and reporting of infection data. In addition to surveillance, public reporting, and sanctions for hospitals with high rates of infections, health care administrators are going to be spending more and more time working to reduce hospital-acquired infection rates. As the public becomes more aware of the direct line connecting outsourced workers, unclean hospitals, and outbreaks of infectious diseases, pressure will build in the United States and Canada to reinvest and hospital environmental hygiene. Improving the wages, benefits, and working conditions of hospital cleaners and other support workers will go a long way toward improving the cleanliness of hospitals, even if the jobs remain outsourced. If hospitals could require contractors to pay the same wages and benefits to their workers as are paid to in-house support workers while maintaining reasonable staffing levels, the consequences of outsourcing would change dramatically. Of course, such rules would also make contracts less appealing and less profitable for contractors; at the same time, those hospitals or health authorities that do opt to outsource would be less likely to experience a drop-off in cleanliness or a surge in infections. A broader approach would be to enact legislation that requires all employers with

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government contracts to pay a living wage. The government would thus ensure that contractors do not derive their profits by impoverishing workers. Another key step should be to strengthen the auditing and regulation of contractors. One of the ways to deal with the serious problems and challenges created by the outsourcing of hospital support services is to dramatically upgrade the auditing of environmental hygiene in hospitals.41 Any outsourcing should be combined with intensive oversight, auditing, data sharing, regulation, and specific exit options that give administrators the upper hand to improve work quality. Hospitals must also address the widespread problem of overcrowding. Overflowing hospitals with high patient turnover are especially difficult to clean and disinfect. In Canada, the hospital bed occupancy rates soared to 95 percent of capacity in 2005 as a result of years of cutbacks in funding that reduced the number of available hospital beds by over one-third. This problem is exacerbated by an aging population, which places further demand on the health care systems in many advanced industrial countries. Still, other first-world countries manage to maintain much lower occupancy rates. For example, in 2005 the Netherlands had an average occupancy rate of 65 percent.42 Increasing public expenditures to build new hospitals and wings would immediately reduce crowding and address the increased demand by an aging population. Several studies suggest that universal screening of patients for MRSA, VRE, and other infectious pathogens can prevent outbreaks.43 Countries such as Denmark and the Netherlands screen all high-risk patients, a step that has helped keep MRSA infection rates below 1 percent, far lower than in Canada, the United States, and the United Kingdom44 In the Netherlands, the search and destroy approach to reducing MRSA infection—a combination of measures that include screening, treatment of MRSA-infected patients, education of health care workers, and daily disinfection of rooms45—has also been highly effective. While this aggressive policy requires upfront expenditures for health care organizations and systems, it more than pays for itself in reduced treatment costs.46 Proactive multipronged approaches have been demonstrated to be extremely effective at reducing rates of hospital-acquired infections. While many reforms can be implemented immediately, others—such as redesigning and building hospitals for improved infection control—will make a big difference in the longer term. In many ways, the traditional hospital seems designed to facilitate the transmission of infection from patient to patient. Carol Werthers, a senior infectioncontrol administrator, sees many changes that need to be made: “I’d like to see them move towards more single occupancy rooms, more rooms that facilitate hand hygiene, more rooms that help people do the best isolation practices and the best infection control practices. We are not there yet on many of our facilities.

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We are asking people to do things but we are not necessarily giving them the resources to accomplish the goal.” Hospitals should be designed or redesigned to reduce the transmission of hospital-acquired infections. Upgrading facilities—including properly ventilating rooms and ensuring adequate bed space between patients—takes money but will result in long-term cost savings by preventing patient infections.47 Maximizing the number of private, unshared hospital rooms and bathrooms for individual patients will also reduce transmission rates.48 Hospitals need to do more than get serious—they also need to get creative. Research suggests that replacing the steel in door handles and other high-contact surfaces with copper could help reduce infections in hospitals.49 Louisa Appleton, an infection-control practitioner, explains how one hospital removed all the patient wash basins and replaced them with sterile one-time-use bathing cloths. Carol Werthers, senior infection-control administrator, recommends removing carpets and fabric-covered furniture from all hospitals. “People don’t even think about it, but why are you bringing cloth into the hospital?” she asks. “You can’t clean it.” Hiring additional front-line personnel who focus on improving infection control is one of the most important steps a hospital can take. As Appleton told me, “Everybody needs to spend a day with an infection control nurse!” They clean the equipment that no one else cleans, they monitor hand-washing, they organize clutter where germs hide, and they lead the response to outbreaks.

Getting There: A Patient Safety Movement Despite the importance of these reforms, they will not be implemented without outside pressure. The short-term profit motive of private health care institutions and the extreme cost-controlling ethic of administrators in public hospitals are difficult obstacles to overcome. As budgets shrink, infection-control programs and staff as well as support workers are easy targets for cutbacks and outsourcing. Yet, ironically, what is needed is precisely the opposite—greater investment in infection-control personnel and programs. Infection-control expenditures should not be viewed as an expense but, rather, an investment in quality of care and long-term cost savings from prevented infections. Much like health promotion and disease prevention, the short-term costs of not focusing on prevention far outweigh the long-term savings to hospitals, patients, and society.50 The major challenge behind infection control is not a lack of knowledge but, rather, a lack of political and administrative will.51 Public and media attention are important for creating a climate of action. Extensive media coverage of the dramatic increases in outbreaks in the United Kingdom after the outsourcing

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of hospital support services raised the profile of the issue and created political momentum for improving infection control. In early 2012, a wave of deadly C. difficile outbreaks in Canada has attracted new media attention to the problem. Each new outbreak will probably increase the pressure for hospitals to implement the reforms needed to improve patient safety and quality of care. In the United States, one great example is the Safe Patient Project sponsored by the Consumers Union, which aims to raise awareness and mobilize support to improve patient safety.52 A patient safety movement that reflects a broad coalition of patient advocates, infection-control specialists, and concerned citizens will be key in creating the kind of sustained pressure needed to bring about these reforms, especially in the current fiscally conservative climate.

Helping the Working Poor in a New Economic Era These, then, are the strangest poor in the history of mankind. They exist within the most powerful and rich society the world has ever known. Their misery has continued while the majority of the nation talked of itself as being “affluent” and worried about neuroses in the suburbs. In this way tens of millions of human beings became invisible. They dropped out of sight and out of mind; they were without their own political voice. Yet this need not be. The means are at hand to fulfill the age-old dream: poverty can now be abolished. How long shall we ignore this underdeveloped nation in our midst? How long shall we look the other way while our fellow human beings suffer? How long? —Michael Harrington, The Other America53

Needless to say, Harrington’s 1962 call to action has yet to be heeded. Indeed, over the last decade poverty has become even more entrenched and widespread in the United States, Canada, and many other advanced industrial countries. One of the main misconceptions about poverty in these countries is that it results from a lack of work ethic or initiative on the part of the poor. In reality, many families living in poverty have at least one member employed in the formal or informal economy.54 In the case of hospital support workers, the benefits of a living wage and improved work conditions would be far reaching: fewer families in poverty, fewer infections in the hospital, fewer deaths, and less suffering. When considering policy reforms, the key is to remember the politics of the possible. Generating the political will to reverse growing inequality and working poverty requires emphasizing the critical importance of universal programs— including education, health care, and tax credits—for reducing inequality and ensuring economic security.

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As William Julius Wilson, sociologist, notes, these universal social policies and programs disproportionately benefit minorities, women, and other vulnerable groups, yet they also appeal to and benefit broad segments of the population. As a result, they are more politically viable and sustainable in the long term than targeted policies.55 Progressive social policies—from higher minimum wages to targeted tax credits—are critically important for reducing poverty rates and improving the quality of life for those working at the bottom of the socioeconomic hierarchy. There is growing acceptance and recognition—even in the United States—that the government can and should play a role in regulating corporations while providing important social services such as health insurance and education. There is also a growing belief that government policies can and should help support corporations and families who have fallen into difficult financial circumstances. The 2008–2012 global economic crisis has demonstrated that government programs such as unemployment insurance can provide important and immediate cushions against the negative effects of downturns. By putting money into the hands of the families most in need, the government can also help stimulate the economy and create economic growth. Supporting workers in the health care and hospitality sectors can generate important innovations and create jobs in post-industrial economies. Tellingly, countries with more generous social safety nets generally experienced less economic dislocation during the crisis. As the world experiences the roller coaster of technologically advanced global economic capitalism, the cushioning effects of social spending promise to become even more important. A major goal for policy reform should be reducing working poverty by fostering the growth of secure living-wage jobs in the expanding service sector. Raising the minimum wage will be a crucial first step. Globally, the fear that an increase in the minimum wage would hurt job growth has been proved to be unfounded. For example, the minimum wage in Australia is now among the highest in the world at $15.96 (Australian) per hour (roughly US$16.28 at early 2013 exchange rates), yet the country boasts a robust service-sector economy. A higher minimum wage ensures that a higher proportion of jobs provide families with a living wage. Increasing the minimum wage also increases the earnings of those with incomes somewhat above the minimum wage, extending the positive benefits far up the job ladder. When firms and employers fail to provide their workers enough income or adequate benefits to meet the needs of poor working families, it is important that government policies provide a hand up for these families, especially those with children. Increasing refundable tax credits for working families to lift them out of poverty is an economically efficient and effective way to dramatically reduce child poverty.

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When progressive social policies are put into law, it’s generally not because politicians have suddenly realized that helping the poor is the right thing to do. As a rule, policy changes are the result of pressure from advocacy groups and grassroots coalitions. Historically, labor unions have been at the center of advocacy reform. Yet with the decline of union representation of the U.S. labor force since the 1970s, the power of labor at the state and federal levels to lobby and organize for worker-friendly policies has declined. The fundamental right of workers to unionize, guaranteed by the United Nations Declaration of Human Rights, is no longer a reality in many regions of the United States because the current union-organizing rules have created nearly insurmountable barriers for workers to organize their workplace. In a post-industrial economy, this requires unionizing jobs in the rapidly expanding health care, hospitality, retail, and education sectors. A fundamental reform of union-organizing rules would reduce barriers to union representation and allow the expansion of secure living-wage jobs. In other countries, labor laws should be reformed to ensure the right of workers to have union representation, especially those in the rapidly growing service sector. The Occupy Movement put the issue of inequality on the agenda in 2011, and now the work must continue to advance the cause of social and economic justice. While many policy makers have focused on the need to reform public assistance programs, these programs do little to help the working poor. Instead, governments should focus on policies that rebuild the safety net to improve the economic security of low-income workers in light of the growing dominance of service employment and unstable part-time work. Reforms should include policies that: • Require all corporations and organizations holding government contracts to pay living wages and offer comprehensive employment benefits for health care, disability, paid sick leave, vacation, and pension. • Improve labor standards, including workplace safety, with opportunities for contract workers themselves to provide input and contribute to improving safety and efficacy on the job through committee participation. • Provide access to affordable high-quality health care and child care for all families. Investments in education are also crucially important for both the workers themselves and for the wider economy. Research clearly shows the benefits of starting early, so high-quality, early childhood education should be a priority. Not only will affordable early childhood education help working families struggling

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to balance work and family life, it will also help create a foundation of literacy, numeracy and other basic skills required for success in today’s economy.56 We should not ignore the central role of infrastructure investments for improving people’s lives. High-quality community centers, preschools, neighborhood houses, parks, and other investments can dramatically improve the circumstances for low-income families. A secure, institution-rich neighborhood dedicated to providing high-quality, accessible services creates a vibrant community, builds social capital, and helps soften some of the consequences of working poverty and income inequality. Many of the hospital support workers in Vancouver report that investments in their neighborhoods have improved their quality of life. Access to high-quality public transit, including frequent bus service and, ideally, rail-based transit, is important for these families so they can access employment, educational, and recreational opportunities. In low-income neighborhoods, investments in highquality programs and services—from health clinics to police—are critically important for mitigating some of the consequences of poverty and making these neighborhoods livable for families. How these policies and programs are funded is also important. The working and middle classes in the United States and in other countries continue to shoulder an increasing tax burden as marginal tax rates for the wealthiest decline. Across-the-board tax cuts provide the greatest reductions in taxes for the wealthy at the expense of resources for programs that disproportionately benefit middleincome and lower-income earners. Middle-income earners now pay a much higher percentage of their income for government retirement programs and for unemployment insurance than their wealthier counterparts. It is time for more fair and progressive tax system that increases the income tax rates for the wealthiest 1 percent. In addition, other programs, such as the mortgage interest tax deduction in the United States, also provide disproportionate benefits to the wealthiest households, allowing them to avoid paying income tax on a significant amount of their income. Although the Canadian tax system is more progressive, it is becoming less so because the wealthy have been given reductions in their tax rates at both the federal and provincial levels. Increasing equality through progressive taxation and transfer programs would improve the lives of the working poor. A truly progressive taxation would directly boost the income of low-wage workers through refundable tax credits, provide a minimal tax burden for middle-class families, and help fund social programs and public services through progressively higher levels of taxation for the highest earners.57 Reversing Bush-era reductions of the capital gains tax from 15 percent back to the original rate of nearly 30 percent would generate significant

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revenues. The new revenue could be used to support important new initiatives such as expanded employment insurance, increased refundable tax credits for low-income workers and families, paid parental leave, early childhood education, urban public schools, public transit, and post-secondary education while lowering the burden of taxation on the middle and working classes. In an era of unprecedented wealth and economic growth, more and more people are living in poverty, with all the physical and psychological risks that go with it. To generate society-level improvements in well-being and life expectancy, prevention programs must take into account social inequality and ensure policies and programs that support the disadvantaged. There is nothing inevitable about the growing inequality and poverty in the wealthiest societies in human history. The arguments that progressive policies and reforms are “unaffordable” in countries such as Canada and the United States simply do not hold up to careful scrutiny; other countries with similar or even lower levels of wealth ensure universal access to quality education, health care, housing, services, transit, and retirement for all people. Indeed this is a cornerstone of a true democracy based on equality of opportunity and voice. What is needed is a sustained movement operating at the municipal, state/provincial, and national levels to address the growing economic inequality, vulnerability, and hardships experienced by working families.

Getting There: A Living-Wage Campaign Living-wage campaigns have the potential to help cleaners, cooks, and other workers at the low end of the employment ladder. In the updated edition of Nickel and Dimed, Barbara Ehrenreich writes that the living-wage movement has “succeeded in passing living wage ordinances in New York City, Los Angeles, and Baltimore, among other cities.”58 In the United States, social movement organizing has contributed to the enactment of living-wage ordinances, statelevel minimum wage increases, and a long-overdue increase in the federal minimum wage.59 Although social movement activists have successfully brought living-wage legislations to many U.S. states and municipalities, it is important that movements also advocate for other non-wage-based policies to improve the lives of lowincome families. The living-wage movement is still in its early stages in the United States and Canada, and much more can and should be done to advocate for a living wage and better working conditions for all workers. In the United Kingdom, the largest public-sector union, UNISON, partnered with community organizations in London to successfully enact a living wage and to change policies related to the outsourcing of hospital support work.60 The UNISON model inspired

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ongoing living-wage campaigns in Vancouver and Victoria, British Columbia, with the active participation of the union representing hospital support workers and First Call, a coalition of advocates for the well-being of children. The idea of a living wage—a wage high enough for parents to support their children and enjoy a decent quality of life—provides a useful framework for workers negotiating better wages and benefits. A living-wage campaign forces employers to look beyond statutory minimum wages and benefits to address the actual cost of living. Diana Mamaril, housekeeper, describes her role in a livingwage campaign: “We went to the candidates, and we present them the calculations for the living wage, and we give them the figures we are making now and comparing it to before it was privatized. The kind of life we are experiencing now that everything is already increased, transit has increased, the price and everything increase and then the salary is just frozen.” She says her experience made her feel stronger and better incorporated into Canadian society. “It made me strong,” she says. “I’m not an activist in the Philippines. Here, I can say whatever I want, I can do what I want.” The living-wage campaign also introduced some of these workers to broader social justice issues. Frederico Hilaga, hospital cook, decided to get involved in the living-wage campaign to help women working in the health care system: “We want a campaign to protect, especially women in the health care system, so they have a better life. These days, in the health care system a lot of them are women, a lot are single mothers, a lot are struggling because the wages are very low. We need to make sure that these people can have a better life and also can enjoy and have some [money] for [their] kids’ education, for retirement.” Hilaga says that a living wage would bring a little justice for low-wage workers. “This private company is earning a lot of money and they don’t want to share it,” he says. “It’s not fair that we work so hard and at the end of the day we still get nothing.” The living-wage campaign organized by the HEU has had many positive outcomes, including the mobilization of its membership and increased awareness of the plight of contracted hospital support workers. The new collective agreement, signed after the campaign, includes higher wages, better benefits, and improved work conditions. Juan Laguatan, housekeeper, says the HEU living-wage campaign helped workers secure some important improvements in their latest contracts. “Before we had 50/50 in the medical, so the employer was paying 50 percent and you were paying 50 percent. But come next year, it will be a 70/30,” he says. And unlike before, when workers had to go through a fair amount of red tape to get reimbursed, “now you get the money right away, the discount right away.” While some workers described major progress, others involved with the living-wage campaign were disappointed that it did not get

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them as much of a wage increase as they had hoped for. For example, although the new agreement did improve wages, the final amount still fell short of the calculated living wage and remains below what they earned prior to the outsourcing of their jobs.61 “We were told that the government doesn’t have the budget to pay the Vancouver Coastal [Health Authority] and that Vancouver Coastal Health doesn’t have the budget to pay the company that I work for,” Daisy Utak, housekeeper, says. “They have a contract for a certain amount, and that’s all the private company can give to us, because they are there to make profit and a portion will be going to the workers.” This is a clear example of how outsourcing allows managers and administrators to “pass the buck” and abdicate responsibility for workers’ well-being. In this way, government health authorities now resemble some multinational corporations, which also rely on the subcontractor excuse to justify sweatshop wages and working conditions in developing nations. With domestic outsourcing, corporate managers do not need to relocate production offshore; they can depend on exploitable workers right at home. At a fundamental level, the problem of outsourcing emerges from broader systemic problems with corporations and the capitalist system. In The Corporation, Joel Bakan writes that “the challenge is to find ways to control the corporation— to subject it to democratic constraints and protect citizens from its dangerous tendencies—even while we hope and strive in the longer term for a more fully human and democratic order.”62 One step toward a solution could be a globalized Living-Wage Certification for service-sector employers.63 This certification could augment existing Social Accountability Standards or Fair Labor Practices certifications. Audits of employers completed by an independent third party would verify that all workers in the businesses’ employ, either directly or through contractors, are paid a living wage. This idea of a Living-Wage Certification for employers has been tested and had early success in London and Vancouver and will, it is hoped, catch on globally. Living-wage movements could push institutions and organizations such as unions, governments, and other institutions to make such certification a requirement for being awarded contracts. The success of the HEU—although limited—demonstrates the important role of social movement organizing for directly and indirectly improving the lives of workers both immediately and in the long term. It is important to emphasize that a living wage is more than a minimum hourly wage guarantee; for many low-income workers, social policies and programs—from subsidized high-quality child care to low-income refundable tax credits—are also critically important for their well-being and quality of life and thus part of what is required for a living wage.

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Outsourcing and the Hospital as an Organization Outsourcing is incompatible with the needs of complex institutions. In hospitals, it destroys the informal and formal mechanisms that exist to guarantee work quality and ensure the safety of patients. Contracting out also means a loss of control, and control is the last thing a hospital wants to give up in the face of an outbreak. What’s remarkable about the case of outsourcing in the Vancouver region is how dramatically and quickly outsourcing reduced the quality of hospital cleaning. While hospital support work does not require many qualifications, these jobs do demand a willingness to complete difficult and challenging tasks. After outsourcing, workers lost the training, tools, compensation, motivation, and supervision that once made it possible for them to do a good job in difficult circumstances. The global growth and expansion of privatization and outsourcing in hospitals have more to do with the logic of capitalism than with any actual fiscal crises or rigorous financial calculations. Advanced economies have more than enough resources to provide decent health care services for all residents.64 When corporations lower wages and roll back job-based benefits for the majority of workers, governments are forced to play a greater role to meet the growing needs of vulnerable families. Yet these same governments continue to slash human welfare services, targeting education, health care, and social welfare. The increasing reliance on contractors to provide services within both public- and private-sector institutions is a major factor behind the erosion of the middle class in advanced industrial economies.65 As multinational corporate contractors increasingly lobby governments—at all levels—for lucrative service contracts, cash-strapped governments are under pressure to turn over these services to the private sector. Similar to what happens in the manufacturing sector, the end result is a shift in power from employees to the employer across the service sector, even in institutions that have yet to embrace outsourcing. The threat of contracting out alone shifts this balance of power and drives the increasing labor market inequality in advanced economies. The growing power of employers over workers coupled with the broader shift toward the service sector has made it that much easier to exploit workers in the new economy. For workers to protect and advance their interests—including ensuring a living wage, decent benefits, and good working conditions—it is critical that they have union representation. Unions can also provide valuable professional development opportunities that can increase the upward mobility of low-income, unskilled workers. In Las Vegas, for example, training arranged

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through the Culinary Workers Local 226 has helped bussers become waiters and waiters become sommeliers.66 There is growing recognition that providing opportunities for low-wage workers to upgrade their skills and move up the job ladder greatly improves the lives of new immigrants and others who work in socalled low-skilled jobs.67 Such opportunities also help attract competent, ambitious workers to the entry-level positions—exactly the kind of workers who can be especially valuable in the fight against hospital infections. The growing awareness of the role of professional cleaning in hospital infection control presents an opportunity to increase the emphasis on skills enhancement and training for workers. Unions and private contractors should work together to expand literacy and improve infection control training; at the same time, they should offer interested workers support and resources, such as subsidies, to transition into more advanced positions in the health care sector. The HEU has provided some training options and support to laid-off workers. They should build on this experience and design a health care training program that mirrors the Las Vegas Culinary Workers Local 226 model for food service workers. Currently the union is working with employers and other stakeholders to embed literacy and expand training for contracted out support workers. These partnerships can create fundamental improvements in work quality.68 It is also vitally important that unions go beyond advancing the interests of their own members and embrace social movement unionism to counter outsourcing and its consequences. For hospital support workers, unions are the most powerful advocates for improving wages, benefits, working conditions, and job security—the very changes required to improve outcomes for patients and workers alike. The experiences of outsourced hospital cleaners in Vancouver form an important lens for us to understand the challenges facing low-skilled workers. Given the dramatic shift to the service sector in advanced industrial economies over the past four decades, the higher levels of poverty, inequality, and social exclusion among hospital workers take on global significance. While much public and academic attention has focused on the harmful consequences of the globalization of manufacturing jobs, outsourcing of service-sector job positions has quietly increased poverty and inequality around the world.69

Shaping Society in the Present and Future The differences between low-road and high-road jobs go beyond the issue of work quality. The characteristics and conditions of jobs shape the socioeconomic distribution within societies and thus also help define the kind of society in

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which we live. When minorities and women are concentrated disproportionately at the bottom of the job hierarchy, their conditions of work—including their wages, benefits, and work schedules—affect their families and children and, by extension, the future well-being of the community. It is the difference between an economy that creates a cadre of struggling wage slaves and one that creates a vibrant middle class. Decent employment policies are an essential cornerstone of public health and consumer safety. The lack of employee protections is particularly severe for lowwage workers in the United States. Over 80 percent of U.S. food service workers do not have paid sick leave.70 If these workers make the responsible decision to stay home when sick, not only do they forgo their income but many also risk losing their jobs. The lack of mandatory paid sick leave means that food service workers often come to work when they are sick and unwittingly place the health and well-being of their customers at risk. In a restaurant, a food preparer or server who is ill could infect many customers—in a hospital or long-term-care facility, the consequences are potentially even more serious. A dietary aide ill with norovirus can easily infect hundreds of health care workers and immunecompromised patients, possibly with fatal consequences. If corporations continue to deny these benefits for their workers, then provincial/state and federal labor laws or universal state mechanisms should mandate them. Whenever hospitals and health authorities in Canada and beyond consider cost-cutting measures and outsourcing support work, they should take a hard look at the consequences for employees, their families, the health care system, and society. Contracting out to franchise multinational corporations creates barriers inside institutions that make it more difficult for them to address complex challenges. It reduces transparency and the institutions’ capacity to control environments while introducing additional administrative complexity. Outsourcing also breaks down informal mentoring and information circuits between health care workers that are critical for improving the quality of service, preventing accidents, and reducing infections. While the current subcontracting system could be made better—more rigorous and aggressive auditing would certainly help—it would be much better to scrap the system and once again employ the workers in-house. The more time I spent talking to hospital support workers, the more I realized that their problem was my problem, too. That’s the take-home message from this study: worker exploitation hurts us all. We suffer alongside the workers in ways that are not always immediate or visible, and we ignore injustice at our peril. When a farmworker in California is not provided with paid sick leave, other people’s children in New York or Toronto might get a food-born infection requiring

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hospitalization or worse. When hospitals take the low road at the expense of worker well-being, patient safety is compromised both in the short and longer term. As governments and institutions become increasingly beholden to bottomline ideology, it’s no surprise that the cleanliness and disinfection of the health care environment once again become public concerns. Where are you now, Florence Nightingale? It’s time for another movement for cleaner, safer hospitals. The new movement must do more than knock down germs. Fundamentally, it must also lift up workers.

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1. All names of respondents, hospitals, and contractors interviewed for this book are pseudonyms to protect confidentiality. 2. Vitez (2010: A1). 3. World Health Organization (2011). 4. Kallen et al. (2010); Perencevich and Diekema (2010). 5. CDC (2012a). 6. Vousden (2008b: 22); Pittet and Donaldson (2005: 1246). 7. McCarter (2008: 15); Zoutman et al. (2003); Canadian Committee on Antibiotic Resistance (2007). 8. McCarter (2008: 1). See also Klevens et al. (2007). 9. This estimate was reported by Zoutman et al. (2003). 10. Graves (2004: 561). R. Douglas Scott II, economist, reports that the low cost estimates of direct HAI treatment costs are $5.7 to $6.3 billion dollars annually, while his own estimates, incorporating Consumer Price Index adjustments for all urban consumers to 2007 dollars, of the direct annual medical costs of HAIs to U.S. hospitals is $28.4 to $33.8 billion dollars (and even higher using inpatient hospital services CPI). In his report, published by the CDC, he estimates the benefits of HAI prevention could be between $5.7 billion and $31.5 billion dollars annually (Scott 2009). 11. Van Iersel (2007). 12. Lawsuits and compensation claims have already been filed in Quebec, Ontario, and Scotland (Pollak 2004: 17). 13. Van Iersal (2007: 11). In the United States, an estimated 1.7 million infections in the United States in 2002 led to approximately 99,000 deaths, and an infection rate of 4.5 per 100 hospital admissions (Klevens et al. 2002, cited in Peleg and Hooper 2010). In other words, approximately 4.5–10% of people hospitalized in the United States will get a hospital-acquired infection (because some people enter multiple times). In the domain of health care–associated infections, at this stage the United States has arguably been more proactive than Canada in terms of enacting reforms such as mandatory surveillance and sanctions for hospital-acquired infections. Yet both countries could and do much more to prevent these infections. 14. Drexler (2002: 128). 15. Fabbro-Peray et al. (2007: 269). 16. Plowman et al. (1999: 12). 17. Wente (2009: A11). 18. “Healthcare associated infections (HAI) are on the rise in B.C. and across Canada, resulting in higher levels of morbidity, mortality, length of hospital stay, health care costs, and institutionalization” (Murphy 2007: 5). 19. Bascetta (2008). 20. Andersen et al. (1999); Nulens et al. (2008); Vos (2007). 21. Pittet and Donaldson (2005: 1247). 22. Pindera (2007); Mulvey and Simor (2009).

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23. Walsh and Fischbach (2009: 47). 24. Landro (2008). 25. Salaripour et al. (2006). St. Michaels Hospital (2013). In another example, twice daily mopping and daily disinfection with a chlorine-based cleaning solution reduced MRSA infections in the geriatric ward of a Japanese hospital. (Masaki et al. 2001). 26. Comptroller and Auditor General (2009), cited in Stanwell-Smith (2012: 31). 27. Rajiv et al. (2011). 28. Dancer (2008: 108). See also Aiello and Larson (2002), Bhalla et al. (2004), Boyce et al. (1997), Carling et al. (2008), Dubberke et al. (2007), Green et al. (2006), Hayden et al. (2008), Lemmen et al. (2004), Maki et al. (1982), Oie, Hosokawa, and Kamiya (2002), Schultz et al. (2003), Talon (1999). 29. Dancer et al. (2009). 30. Carling and Bartley (2010: 541). The five studies are VRE (Hayden et al. 2006; Martinez et al. 2003; Huang, Datta, and Platt 2006; Drees et al. 2008; Datta et al. 2009; Hota et al. 2009), MRSA (Datta et al. 2009; Dancer et al. 2009), and A. buamanni: (Wilks et al. 2006). 31. According to Carling and Bartley, “Eight recent studies have now confirmed that patients occupying rooms previously occupied by patients with vancomycin-resistant Enterococcus (VRE), MRSA, Clostridium difficile, and Acinetobacter baumannii infection or colonization have on average a 73% increased risk of acquiring the same pathogen than patients not occupying such rooms” (2010: 541). The eight studies are VRE (Hayden et al. 2006; Martinez et al. 2003; Huang, Datta, and Platt 2006; Drees et al. 2008; Datta et al. 2009), MRSA (Huang, Datta, and Platt 2006; Drees et al. 2008; Datta et al. 2009; Hardy et al. 2006), C. difficile (Shaugnessy et al. 2008), and A. baumannii (Wilks et al. 2006). 32. Messing (1998); Torrence (1998); Appelbaum et al. (2003); Tierney, Rominto, and Messing (1990). A New Economics Foundation (2009) report compares the social value of different professions relative to their compensation, and estimates hospital cleaners provide £10 in social value (through reducing infections and improving health outcomes) for each £1 paid. 33. Christiansen et al. (2004); Lynn et al. (2004); Pimentel et al. (2005); Sample et al. (2002). 34. Silversides (2009a: 574). This article provides the specific example of the Nanaimo hospital discussed in chapter 5. 35. Berens (2002). 36. Quoted in ibid (19). 37. Ibid.; Appelbaum et al. (2003). According to an article by Carey and Dorr (2004) in Health Affairs, there has been a 1.50-fold increase, particularly in rural areas, in the number of U.S. hospitals contracting out management from 1980 to 2000. 38. Appelbaum et al. (2003). 39. Berens (2002). 40. Ducel, Fabry, and Nicolle (2002); O’Connell and Humphreys (2000). Disinvestment and outsourcing makes working conditions more dangerous, resulting in a surge of on-the-job injuries (Quinlan and Bohle 2008). It also significantly reduces wages and benefits, exacerbating problems of understaffing of hospital support work positions and creating excessively high levels of stress for workers who remain (Buchanan 2000). Distracted, stressed, and exhausted workers are less careful and are more likely to cut corners. Disinvestment and outsourcing reduces the quality of work completed by these workers and thus contributes to increased risk of infections and outbreaks. 41. According to Marjorie Griffin Cohen, political scientist, “the American Hospital Association conducted a survey of approximate 30 per cent of all U.S. acute care hospitals with 100 or more inpatient beds. The main findings of this study indicate that there is no

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reason to be optimistic about the benefits of re-engineering—‘re-engineering appears to increase hospital costs relative to costs of competitors.’” She goes on: “In general the survey found that ‘re-engineering not only may not improve performance, but may actually be detrimental to it’” (2001: 23; quoted study is Walston, Burns, and Kimberly 2000: 1374, cited in Cohen 2001). Cohen also cites the findings of a study on patient and employee satisfaction at a Toronto hospital post-outsourcing of housekeeping management, food services, and “stores.” The surveys revealed, “Patient satisfaction with housekeeping (which had contracted-out its management) was rated as ‘below average’ performance, while support services overall were considered to be at the very best, ‘average’” (Stonehouse, Hudson, O’Keefe 1996, cited in Cohen 2001: 24). As for the hospital staff, “The survey determined that staff below the senior management level were very unhappy with work in the facility, and the hospital was found to be below average in almost all areas surveyed. (The comparison group was a database of 100,000 employees in many industries across North America.)” (Cohen 2001: 24). This is reinforced by the findings of Aiken, Clarke, and Sloane (2000); Gordon (2005); Weinberg (2004); and Woodward et al. (1999). Rampling et al. (2001) go as far to argue, “In the long term, cost-cutting on cleaning services is neither cost-effective nor common sense (Rampling et al. 2001: 115, cited in Davies 2010: 457). Marchington et al. (2005) and Rubery et al. (2002) detail some of the negative consequences for organizations. The following research details some of the negative consequences of outsourcing on the mental health and well-being of employees, including inspiring feelings of anger, loss of control, injustice, alienation, and powerlessness: Morgan (2009); Morgan and Symon (2006); Coyne-Shapiro and Kessler (2002); Hallier (2000); Kinnunen et al. (2000); Rousseau (1995); Sverke, Hellgren, and Näswall (2002); van Knippenberg and van Schie (2000). Hall (2000) reports that, based on case studies of three large organizations, outsourcing reduced employee commitment, training, and skills losses. According to Augurzky and Scheuer, in Germany “many service firms [private contractors] have underestimated the problems associated with servicing an institution like a hospital which in many regards is different from industrial clients. Therefore, hospitals complained about the low quality of the services provided from the outside compared to those they were used to” (2007: 264). Their findings show that “Neither hospitals nor service firms have been entirely satisfied. Hospitals have sometimes complained about the quality of the services which they receive from outside and the service firms have had their hopes of higher profits dashed” (2007: 264). 42. Stanwick (2009); Gindin and Hurley (2012). 43. Andersen et al. (2002); Archibald et al. (1997); Denton et al. (2004); Hugonnet, Chevrolet, and Pittet (2007); Griffiths, Renz, and Rafferty (2008). 44. For example, Dana Weinberg, sociologist, in Code Green (2004), and Suzanne Gordon, journalist, in Nursing against the Odds (2005), describe how hospital restructuring affects nurses, while Alonzo and Simon (2008) explore the effects on doctors. Other studies also have found increases in worker depression, anxiety, and exhaustion. Based on a survey of nine hundred employees at a major Ontario teaching hospital over a 2-year period, administered at three times, Woodward et al. (1999) found that rapid organizational change resulted in increased worker anxiety, depression, and exhaustion, causing them to conclude that cost reductions at hospitals hurt the quality of the workplace. Burke (2003) also found, based on a longitudinal survey, that nurses reported lower job satisfaction, increased burnout, and lower psychological well-being after hospital restructuring and downsizing. One review of research on the consequences of health care restructuring and outsourcing found that precarious work arrangements were associated with negative outcomes for the occupational health and safety of workers, including increased injury, disease, and on-the-job risk (Quinlan, Mayhew, and Bohle 2001). In some countries, the privatization of certain kinds of health care services results in some employees earning higher salaries and better benefits. For example, privatization

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in Finland in the 1990s allowed doctors to earn more money in private practice than as salaried municipal employees, helping address a shortage of doctors (Vuorenkoski and Mikkola 1997). In a study of contracting out and the use of temporary agencies in the automotive supply industry, hospitals, and schools, Erickcek and colleagues found that workers were most negatively affected by outsourcing when relatively highly paid jobs were contracted out on a long-term basis. In other cases, when temporary workers supplemented in-house work or were used on a short-term basis, this has been found to have little adverse effect on in-house employees. Sometimes temporary employees were screened for potential long-term positions, opening up opportunities for those with weaker work histories to secure nontemporary positions (Erickcek, Houseman, and Kalleberg 2002). 45. Quinlan and Bohle (2008). The occupational health and safety of workers declines when workers become contingent, and this trend most negatively affects the most vulnerable workers, including women, minorities, and youth (Quinlan 1999). 46. Beardwood and Alleyne (1999) argue that hospitals are contracting out a range of services—from food service to maintenance—in the hopes of getting better service for lower costs. They point out that without careful management there can be substantial costs from outsourcing, including hospitals becoming tied to an underperforming service provider or absorbing the high costs related to early termination of a contract. 47. Richard G. Wilkinson, epidemiologist, and Kate Pickett, in The Spirit Level (2009), provide an impressive range of evidence that higher levels of economic inequality are associated with poorer health outcomes—including life expectancy and infant mortality rates—along with a host of serious social problems in advanced industrial countries. From the social democracies of Sweden and Finland to more capitalistic countries such as Canada, the United States, and the United Kingdom, the growth of outsourcing in the service sector is rapidly swelling the ranks of the working poor. As Jacob Hacker, political scientist, argues in his book The Great Risk Shift (2006), current economic trends reflect a downshifting of risk to individual workers. The process also pushes corporate profits higher and creates skyrocketing levels of wealth for the most privileged. Privatization and outsourcing in the hospital represent a clear example of this trend. The workers at the bottom of the chain face the most on-the-job hazards and the least amount of job security. Guy Standing (2008: 19), economist, argues that this shift erodes the informal social contract between capital and employees to where employees now are required to be flexible and insecure. The consequences of such flexible work arrangements are generally most severe for workers at the bottom of the labor market (Aneesh 2006: 46). A. Aneesh’s research on call center workers in India examines the consequences of night work on employees’ lives. He argues, “while the flexibility of loading and unloading workers does help the economic system to achieve greater efficiency, it is at the same time disruptive of the lifeworld, which is harnessed more and more toward system imperatives” (Aneesh 2006: 48). In the developed world, sociologists have pointed to the way that nonstandard work hours are reshaping lower-level service workers lives, from Harriet Presser’s Working in a 24/7 Economy (2003) to Peter Alder and Patti Adler’s Paradise Laborers (2004) on hotel workers in Hawaii. Despite the promising rhetoric about the benefits of flexibility, research has demonstrated that this practice has burdened workers and increased on-thejob stress (Coyle 2006). Despite their ubiquity, these workers and their struggles remain largely invisible, both in their workplaces and in the broader community. Their struggles are also invisible in the poverty research literature, which has focused largely on recipients of public assistance and the urban poor (Newman 2000). Increasingly poverty in the United States, Canada, the United Kingdom, and several European countries is associated less with unemployment than with low wages. Many people who work even full-time hours remain unable

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to lift themselves and their families out of poverty. According to John Iceland, sociologist, in Poverty in America, “nearly half of the poor of working age work at least part-time” (2003: 3). As living-wage jobs become increasingly unavailable, many low-wage workers are experiencing economic hardship and lack basic benefits such as health care and retirement savings plans (Greenhouse 2008: 7). Much of the research on the working poor also challenges “culture of poverty” arguments that often blame the poor for their own plight, and it exposes how the causes and consequences of poverty are embedded in the social system (Jurik 2004; Munger 2001), including how government employment policies shape the conditions of work in low-wage service sector jobs. Other scholars interested in the working poor have focused on low-wage workers in specific workplaces, including fast food outlets, garment factories, call centers, grocery stores, and the hotel and hospitality industry (Newman 2000; Reiter 1995; Chin 2005; Rosen 2002; Buchanan 2001; Tannock 2001; Ehrenreich and Hochschild 2002; Hondagneu-Sotelo 2001; Ozyegin 2001; Parrenas 2001Pratt 2004; Adler and Adler 2004; Sherman 2007; Wells 2000; Zuberi 2006.) Much of this research has demonstrated how difficult it is for workers to get by with low-pay, limited or nonexistent benefits, lack of decent affordable child care, and odd-hour schedules that make it hard to successfully combine work and family life (England, Budig, and Folbre 2002; Levitan and Shapiro 1987; Shulman 2005; Heymann 2003; Johnson 2002; Schwartz and Weigart 1995; Zuberi 2006; Shipler 2004; Tannock 2001; Edin and Lein 1997; Hurtig 1999; Chaudry 2004; Adler and Adler 2004; Presser 2003.) 48. This breach of signed collective agreements by a newly elected government resulted in a flurry of lawsuits by the Hospital Employees’ Union. First, the union won the right to reorganize these workers. Then, they signed new collective agreements with the corporations, which increased wages from $10.25 to approximately $13 per hour and made small improvements in benefits. Most important, the Supreme Court of Canada ruled that the tearing up of collective agreements violated the Canadian Charter of Rights and Freedoms of the Canadian Constitution, thus for the first time enshrining the right to collective bargaining and mandating that these agreements be respected by governments. See also Cohen (2006); Lee and Cohen (2005). 49. According to Stinson, Pollak, and Cohen (2005), 8500 jobs were contracted out from 2003 to 2005. 50. Ibid. Prior to privatization, health care support workers in British Columbia had the lowest gender wage gap among all jurisdictions in Canada due to successful HEU bargaining strategies (Cohen and Cohen 2004). 51. As in many cases of outsourcing, cost saving was used as the reason for contracting out these services (Erickcek, Houseman, and Kelleberg 2003). The health authorities claimed that savings were transferred into, for example, extra expenditures for nurses. 52. Cohen (2001); Zuberi (2006). 53. The support worker respondents were recruited through invitations to participate in the study that were distributed at union meetings as well as through snowball sampling. The interview data are supplemented with participant observation at hospitals as work sites as well as open-ended interviews with union leaders and other stakeholders in the health care sector. There are some issues of bias with this sampling methodology, but it has allowed me to access a sample that has been difficult to study and a group for which survey approaches have not yielded the most interesting findings. The data were analyzed with the help of Qualitative Social Research’s NVivo 8 software. 54. In Vancouver, as in many major metropolitan areas, hospital support jobs are most often completed by ethnic minorities, frequently immigrants and refugees from all over the globe. Ninety-one percent of the support worker respondents were born and raised outside of Canada and 86% are over the age of forty. Their low wages condemn them to poverty-level incomes: 74% continue to have annual incomes of less than the Vancouver

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living wage of $30,000, while 17% make under $20,000. It is not surprising that nearly one-third of the respondents interviewed work at a second or even a third job to make ends meet. 55. As calculated by an advisory group organized by a Vancouver-based think tank called the Canadian Centre for Policy Alternatives—BC Office, in 2012. 56. See Zuberi (2006). 57. Herdt-Losavio et al. (2009). Hospital cleaners face additional risks of occupationally acquired infections (Sepkowitz 1996). 58. British Columbia Association of Medical Microbiologists (2009). These statistics are for the entire province of British Columbia. The health authorities in the Northern and Interior Health regions—which serve 25% of the population—did not privatize and outsource their support jobs. Even if the data were available, comparing the trends in these authorities with the other ones might not make sense because they serve very different populations; the Northern and Interior Health authorities serve smaller, rural communities, in contrast to the major metropolitan areas of Vancouver, Victoria, and Nanaimo in southwestern British Columbia. This difference also makes them less likely to transmit infections. 59. Gravel et al. (2009); Canadian Nosocomial Infection Surveillance Project ([CNISP] 2007; 2009: 5; 2010), cited in Gindin and Hurley (2012). 60. British Broadcasting Corporation ([BBC] News 2005), cited in Davies (2010: 449). 61. Davies (2010: 449). Butler and Batty (2001) report that most of “filthiest hospitals” identified in NHS audits were part of health trusts that had privatized their hospital cleaning. 62. Office for National Statistics ([ONS] 2008: 69–70), cited in Davies (2010: 446). 63. Augursky and Scheuer (2007); Jaerling (2008); Gautié and Schmitt (2009). 64. UNISON (2008). 65. Price, Pollock, and Shaoul (1999). Many scholars argue that these reforms threaten universal health care coverage, democratic accountability, equity, and comprehensive care (Price, Pollock, and Shaoul 1999). Player and Leys (2008) argue that the penetration of the private health care industry into the public health care system in the United Kingdom since 2000 has allowed the entry of actors with histories of fraud and has transferred risk from private corporations to the state. 66. Cohen (2001). 67. For private for-profit or nonprofit hospitals, the immediate explanation for outsourcing is almost always the short-term cost savings achieved by contracting out service work. It is more difficult to understand the incentive for public health care systems to turn to private contractors. Generally these short-term cost savings are argued to be essential for covering budget shortfalls. Given limited resources, hospitals and/or health authority officials argue that contracting out will free up critical resources for other health care priorities— such as hiring additional nurses or increasing doctor’s salaries. Other political factors help explain the expansion of outsourcing in the health care sector in certain cases. In the case of the Finnish health system, for example, scholars have pointed to institutional path dependency and the devolution of health care administration to small local authorities with limited democratic accountability to explain the introduction of privatization (Hakkinen and Lehto 2005). Based on a meta analysis of studies of water and waste privatization since 1965, Bel and Warner (2006) found there is no consistent relationship between privatization and cost savings (or productivity). Their findings refute earlier research by Domberger (1998), Domberger and Jensen (1997), and Domberger and Rimmer (1994) that report on cases of public sector contracting out that reduced costs, while maintaining quality (based on perceptions of quality surveys). When it comes to hospital cleaning contracts, Milne found that in the United Kingdom high costs of entry limited competition

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for contracts and that private contractors earned little or no profit in the first seven years of the contract (Milne 1993). 68. Harrison and Callthorp (2000). Naomi Klein argues in The Shock Doctrine (2007) that corporations and their lobbyists are often actively looking to take advantage of crises to secure contracts and to advocate for private-sector delivery of public services. During the economic recession in Sweden in the late 1990s, the government was under pressure to reduce public expenditures and thus turned to greater privatization of health services as a means of controlling spending. With the funding crisis, political representatives became more receptive to the idea of privatization, and advocates of reform eventually overcame resistance from policymakers and health care professionals (Harrison and Callthorp 2000). The decentralization of responsibility to regional health care councils in the 1990s also facilitated the rapid privatization of services, despite the Swedish single-payer public health care system (Hogburg 2007). 69. Cabiedes and Guillan (2001). 70. Pollak (2004: 15). 71. The Vancouver Coastal Health Authority annual expenditures in 2008–2009 were approximately $3 billion (Vancouver Coastal Health Authority 2009: 15). 72. Hospital Employees’ Union (2008). This settlement resulted from a lawsuit filed by the HEU in response to provincial government legislation enacted to facilitate outsourcing of hospital cleaning and support services, which effectively cancelled the existing collective agreement covering hospital support workers. Although the Supreme Court of Canada ruling in this case did not mandate that these jobs be returned in-house and contracting out be rolled back, it included a financial settlement for HEU workers and at the same time enshrined the sanctity of collectively bargained agreements. The outsourcing of health support services in British Columbia was challenged on many fronts. Along with the legal challenge, in April 2004 the HEU also launched an illegal strike opposing the privatization of hospital cleaning and support jobs, which almost led to a general sympathetic strike by unionized workers across a wide range of economic sectors in British Columbia (Isitt and Moroz 2007). 73. According to Eileen Appelbaum and colleagues, “On the one hand, because food service and housekeeping are not typically seen as distinct sources of hospital success or expertise, some hospital administrators have outsourced these functions or their management to external firms that specialize in these areas. On the other hand, food service workers, housekeepers and nursing assistants all have direct contact with patients and those contacts can affect patients’ experiences in the hospital and satisfaction with care” (2003: 85). 74. For example, research on a rural hospital in Australia found that transaction costs were only one important factor explaining which hospital services were privatized; other factors, including political imperatives and opportunistic behavior, were also important in explaining why some services were outsourced and others kept in-house (Young 2003). Another comparative study of outsourcing in the Australian health care sector points to the central role of managers for explaining when outsourcing occurred (Young 2005). 75. Biais and Perotti (2002: 240). Hence privatization must be understood as being more than a rational economic decision; it is also as a political decision with profound implications at the societal level. 76. This is even true in “progressive” European democracies such as Germany and the Netherlands. According to Virginia Doellgast, Ursula Holtgrewe, and Stephen Deery, industry studies scholars, “workplace-level collective bargaining arrangements and inhouse (compared to outsourced) status also were associated with significantly higher measures of job quality across countries. Findings suggest that within CMEs [coordinated market economies], dual union/works council representation continues to provide

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important support for job security, participation, and discretion, but that outsourcing can effect a partial escape from this institution” (2009: 489). 77. These findings are based on research studying two privately funded UK public hospitals (Givan and Bach 2007). 78. Because privatization and outsourcing tend to replace stable living-wage jobs with low-wage insecure jobs, their expansion helps explain the rising rates of economic inequality in the post-industrial era. Pretax and transfer income inequality has increased dramatically in most developed countries concurrently with de-industrialization. Scholars have identified a variety of explanatory factors for the growing inequality, including the decline of union power in these countries (Aldersen and Nielsen 2002). This is clearest in the U.S. case, where union representation of the labor force has declined sharply since the late 1970s. Yet the way that outsourcing operates as a political-economic phenomenon has also eroded the power of unions to negotiate collective agreements. Understanding the growing gap between the haves and have-nots in the new economy requires a careful examination of the consequences of neoliberal reforms, including the retrenchment of social welfare, reductions in employment protection, and disinvestment in and privatization of public assets and infrastructure (Leitner, Peck, and Sheppard 2006; Peck and Tickell 2002). The expansion of neoliberal policies has also given rise to “just-in-time” and temporary work (what is known in the literature as “contingent work”), as well as the offshoring, outsourcing, and contracting out of manufacturing and service-sector jobs (Beardwood and Alleyne 1999). Together, these political-economic reforms are reshaping the socioeconomic hierarchy, with serious negative consequences for and growing exclusion of those toiling at the bottom. 79. Mishel, Bernstein, and Allegretto (2007), in Greenhouse (2008: 7). 80. In her book, The Betrayal of Work, Beth Shulman describes the working poor in the United States: “They are America’s super-exploited. And this is both a shame and a challenge of historic proportions. A shame because America has always honored work, yet now finds itself in the position of degrading it. A challenge because whatever one thought of America’s welfare poor, few people are making money off them. The same cannot be said of our new working poor. Corporations, corporate executives, shareholders, and American consumers are making money off them. Thirty million Americans, one out of every four workers, makes less than $8.70 per hour. And these low-wage, no benefit jobs translate into billions of dollars of profits, executive pay, high stock prices, and low consumer prices” (2005: 4–5). As Shulman points out, “[The working poor] are all around us: security guards, nurse’s aides and home-health-care aides, child-care workers and educational assistants, maids and porters, 1–800 call-center workers, bank tellers, data-entry keyers, cooks, food-preparation workers, waiters and waitresses, cashiers and pharmacy assistants, hair dressers and manicurists, parking-lot attendants, hotel receptionists and clerks, ambulance drivers, poultry, fish, and meat processors, sewing-machine operators, laundry and dry-cleaning operators, and agricultural workers” (45–46). 81. Shipler (2004: 10). 82. Edin and Lein (1997); Newman (2000). 83. Leitner, Peck, and Sheppard (2006); Peck and Tickell (2002). Given the role of the public sector as a major source of secure living-wage jobs, privatization has profound and multidimensional repercussions for economies and societies. 84. Beiser (1999); Creese and Kambere (2003); Reitz (2003); Waldinger and Lichter (2003); Reitz and Breton (1994). 85. Ibid. 86. Cohen and Cohen (2004, 2006); Stinson (2006); Sylvia Fuller, sociologist, argues that, “the B.C. public sector does not pay above-market wages to workers in general, but only to women. Rather than view women as ‘overpaid’ in the public sector, it may be more accurate to see them as relatively underpaid in the private sector” (2005: 426).

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87. Galabuzi (2006). 88. Luxton and Corman (2001: 4). 89. Ludwig, Groot, and Van Merode (2009). The inclusive system of collective bargaining in the Netherlands limits the potential cost savings for hospitals from outsourcing (Gautié and Schmitt 2009). Yet even the Netherlands is not immune from this neoliberal trend; even though hospital cleaners are in-house in the Netherlands, approximately 9 percent of hospital kitchen staff have been outsourced (Ludwig, Groot, and Van Merode 2009). 90. Westergard-Nielsen (2008). Although hospital cleaners are employed in-house and recently have had to upgrade their skills to include housemaid and porter functions to improve patient care, public-private partnerships are employed in laundering and catering hospital services (Pederson 2005). National collective bargaining limits the potential cost savings for hospitals from outsourcing (Gautié and Schmitt 2009). 91. Gindin and Hurley (2012). The Auditor General of Scotland (2000, 2003a, 2003b) identifies serious problems with hospital cleaning and environmental hygiene after privatization and outsourcing of these services. 92. Scottish Health Finance Directorate (2008). This new policy represents a reversal of the previous trend of privatization and contracting out of hospital support jobs in Scotland. The annual cost of Private Finance Initiative (PFI) National Health Service projects in Scotland had been projected to increase by a factor of five from 2005–2006 to today. (Hellowell and Pollok 2007). 93. Gindin and Hurley (2012). 94. When Spain elected a conservative government in 1996, health care services were rapidly privatized to the point of constructing private hospitals. Yet by the early 2000s, public outcry about the consequences of the privatization of health services led to a growing distrust of neoliberal health care reform policies and a stalling of privatization (Sanchez Bayle and Bieres Cal 2001). Spain has halted the privatization of its health care system. CHAPTER 2

1. Drexler (2010); Keiger (2009). 2. Collingnon, Grayson, and Johnson (2007); Clements et al. (2008); Griffith et al. (2000); Kramer, Schwebke, and Kampf (2006); Hota (2004); Johnston et al. (2006). 3. Asoh et al. (2005); Boyce (2007); Das et al. (2002); Hardy et al. (2004). Shimori et al. (2002); Sexton et al. (2006); Trillis et al. (2008). Other concerns include contamination of magnetic resonance imaging (MRI) equipment and fabric (Rothschild 2008). 4. Hardy et al. (2004). 5. Klevens et al. (2007b); Walsh and Fischbach (2009: 44). MRSA infections increased to colonize or infect an estimated 29,000 patients in Canada in 2006 (Priest 2008b: A7). Simor et al. (2001) also reports an increase in MRSA in Canadian hospitals based on five years of national surveillance. 6. Mayo Clinic Staff (2010); Priest (2008a: A1). Based on a retrospective analysis of a ICU unit over five months in a hospital in England, Dancer et al. (2009) found that nurse understaffing and hygiene failures, especially at high-touch sites, was associated with enhanced risk of MRSA infection. 7. Walsh and Fischbach (2009: 44). 8. Provincial Infectious Diseases Advisory Committee ([PIDAC] 2007: 17–18). 9. According to French et al. (2004), culturing swabs taken from surgical wards in a London teaching hospital revealed that over 74% were contaminated with MRSA; shockingly, 66% remained contaminated after cleaning. Numerous studies have revealed high

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levels of environmental contamination of surfaces in hospitals from door handles to room curtains (Dancer 2008, 2010; Goodman et al. 2008; Hayden et al. 2008). 10. Andersen et al. (2002: 22). 11. Kallen et al. (2010). 12. National Institute for Occupational Safety and Health (2007). 13. Wertheim et al. (2004); Vousden (2008a: 12). 14. Elstrøm and Aavitsland (2008: 2730). 15. Henry (2008: 2–3). The number of patients with C. difficile infections in the United States increased from approximately 82,000 in 1996 to 178,000 in 2003 (McDonald, Owings, and Jernigan 2006). 16. Ibid. 17. McDonald et al. (2005). 18. O’Conner, Johnson, and Gerding (2009: 1913); Henry (2008: 2–3). According to Robert Stanwick, chief medical officer of the Vancouver Island Health Authority, “This more toxic strain of C. difficile was associated with the nosocomial crisis in the Province of Quebec where it was implicated in contributing to hundreds of deaths. This particular bacterium continues to evolve and a hyper-toxogenic ribo type 027 clone has been recognized in eastern Canada recently” (2009: 10–11). 19. Eggertson (2005). 20. Office for National Statistics (2008b). This virulent strain of C. difficile is also highly prevalent in Vancouver (Stanwick 2009: 10–11). 21. Turner (2008). See also Sunenshine and McDonald (2006). 22. Henry (2008: 5). 23. Boyce (2007: 51); Henry (2008): 5; McCarter (2008). 24. Quoted in Pindera (2007: 915), cited in Murphy (2007: 30). 25. Carling, Briggs, Hylander, et al. (2006). 26. Martinez et al. (2003). 27. Ibid. 28. Trottier et al. (2007); Cambridge University Hospitals NHS Foundation Trust (2006: 9); British Medical Association, Board of Science (2006). Markogiannakis et al. (2008) describe how environmental contamination and colonization of health care workers hands resulted in a deadly outbreak of imipenem-resistant A. baumannii in a Greek hospital ICU. 29. Wiener et al. (1999); Manges et al. (2001); Wisplinghoff et al. (2004); British Medical Association, Board of Science (2006). 30. Walsh and Fischbach (2009: 47); Herriman (2010); Pindera (2007); Mulvey and Simor (2009). de Lassense et al. (2006) describe an outbreak of Glycopeptide-intermediate Staphylococcus aureus (GISA) at an ICU in France. 31. Walsh and Fischbach (2009), Pitout (2010). The ability to successfully treat bacterial infections is a critically important pillar of many modern medical procedures, including successful surgeries. The increasing threat from antibiotic-resistant hospitalacquired infections, particularly to immunocompromised patients, represents a major challenge to patient safety. 32. CDC (2012b). Kumarasamy et al. (2010) describe the prevalence and epidemiology of the New Delhi metallo-β-lactamase 1 (NDM-1) gene in India, Pakistan and the United Kingdom which confers carbapenem resistance in the journal Lancet Infectious Diseases. 33. British Columbia Ministry of Health (2005). 34. Barker, Vipond, and Bloomfield (2004); Lynn et al. (2004). 35. Tyshenko (2010); Henry (2009); Canadian Union of Public Employees (2009: 1). 36. Tysenko (2010).

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37. This is also chillingly described by Maryn McKenna, medical journalist, in Superbug: The Fatal Menace of MRSA (2009). 38. Ibid., 48. 39. Henry (2008: 3). 40. French et al. (2004). See also Carling, Briggs, Perkins, et al. (2006); Boyce (2007); Barker, Vipond, and Bloomfield (2004); Dancer (2008); Griffith (2007). 41. Orr et al. (2002). 42. Globally, the two major trends in terms of hospital support work go hand in hand: disinvestment and outsourcing. In hospitals, cutbacks have consequences. Investigators in the United Kingdom found that hospital-acquired infections increased soon after hospitals slashed funding for cleaning and began outsourcing their labor (Davies 2009: 4; Pratt et al. 2007). 43. Korcok (2002). 44. Vaughan (1995). 45. Korcok (2002). 46. Canadian Institute for Health Information (2005: 2–3), cited in Canadian Union for Public Employees (2009: 13). 47. Canadian Association of Emergency Physicians (2005), cited in Canadian Union of Public Employees (2009: 13); Gindin and Hurley (2012). 48. Pollak (2004: 4, 17). 49. Henry (2008). 50. Pollak (2004: 4, 17). 51. Clements et al. (2008). 52. Pollak (2004: 17). 53. Henry (2008: 3). 54. Cohen (2001). 55. Hospital cleaning staff workers are not the only ones caught up in the rush to cut health care costs. Across the board, funding cuts and the introduction of marketinspired “managed care” have also made it difficult for hospitals to retain high-quality staff in the United States (Randall and Williams 2006; Denton et al. 2005). What are some of the underlying causes of these cuts? In Canada, tax cuts—specifically across-the-board income tax cuts—have created unnecessary budget crises at the local, regional, provincial, and national levels, exacerbated by the recent economic recession. The frequent mantra that health care expenditures are unsustainable creates a crisis atmosphere where administrators unnecessarily look to achieve shortterm savings at the cost of negative long-term consequences. Across the United States, Canada, and the rest of the advanced industrialized world, governments have been dramatically reducing the tax burden for their wealthiest residents. Across-the-board income tax cuts benefit the highest earners the most; reductions in capital-gains and other investment taxes also favor the wealthy. Despite decades of economic growth and productivity gains in these economies, deepening tax cuts have contributed to growing budget crises. 56. The sample is composed primarily (81%) of women. The average age of the respondents is 49-years-old, and many (44%) are married or living common law relationships. Another 30% are single, and 21% are divorced or separated. The vast majority of respondents (81%) are ethnic minorities, with immigrants from the Philippines being the largest group at 42%. Most (88%) of the sample population are immigrants; 53% of these arrived in Canada before 1991. And the majority (70%) of respondents had completed at least a post-secondary-level education. 57. Given what we know about sector wage effects, just as higher wages paid by one firm result in wage increases across the sector, the downward wage pressure created by the mass outsourcing of these jobs in the public health care system will likely result over

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the long term in the stagnation or even reduction in wages for other workers in the same sector, especially in similar or somewhat higher job positions. 58. Of course, the workers’ backgrounds and experiences do not mean that they should be discounted as unwilling or unable to advocate effectively for their rights, improved work conditions, and social justice. Ruth Milkman highlights in L.A. Story (2006) how many of the most active people involved in labor organizing and movements in the United States today are Hispanic immigrant workers. In fact, the Living Wage Movement in British Columbia that has emerged, in part, as a response to this outsourcing has secured several important victories, both at the workers’ collective bargaining table and in the passage or consideration of living-wage ordinances in several British Columbia municipalities. 59. Quoted in Pollak (2004: 37–38). 60. Cleaners have “significant risks for musculoskeletal problems” (Milburn and Barret 1999; Torgen, Nygard, and Kilbom 1995, both cited in Seifert and Messing 2006: 558). They also have “health problems derived from exposure to cleaning products” (Karjalainen et al. 2002; Rosenman et al. 2003, both cited in Seifert and Messing 2006: 558). 61. Some might posit that these responses are just examples of false consciousness. Yet the veracity and persuasiveness of the workers’ descriptions of why they like or even love their jobs merit serious consideration. On the one hand, it is true that many define their pride in terms of being employed, in opposition to those even more marginalized than themselves. On the other hand, many also describe feeling proud and having a sense of accomplishment in their actual work routines. While cleaning and food service work is economically and socially devalued, workers argue that the work they do plays a particularly important role in the hospital settings. Many also treasure and cherish their relationships with co-workers, other health care workers and professionals, as well as patients. CHAPTER 3

1. My findings support the insights of other research on hospital housekeepers and their role in hospitals; see, for example, Davies (2010: 454). Some of the findings on understaffing, injuries, and lack of training were previously presented in Zuberi and Ptashnick (2011). 2. Stanwick (2009). 3. Stanwick (2009: 38). 4. As discussed in greater detail in chapter 5, this is why it is so problematic that most hospitals rely almost exclusively on visual assessment to evaluate cleanliness. A June 2010 article in the American Journal of Infection Control reported: “Currently, 89% of a large sample of U.S. acute care hospitals confirmed that they perform visual assessments of cleanliness during regular environment of care rounds as the primary means for evaluating cleaning practice in their hospitals” (Rollins 2009, cited in Carling and Bartley 2010: S41). 5. Canadian Union of Public Employees (2009: 9). 6. This problem is not unique to contractors in Vancouver. For example, hospital cleaners in the United Kingdom reported similar issues with inadequate supplies (Davies 2005, cited in Canadian Union for Public Employees 2009: 12). 7. Pollak, Cohen and Stinson (2005). 8. Canadian Union of Public Employees (2009). 9. Alfa et al. (2008, 2010); Barbut et al. (2009); Barker, Vipond, and Bloomfield (2004); Boyce (2009); Boyce et al. (2008); Carling, Briggs, Perkins, et al. (2006); Carling et al. (2010); Cooper et al. (2007); Griffith et al. (2000, 2007); Loveday et al. (2006); Canadian Union of Public Employees (2009); Dancer (1999, 2008); Denton et al. (2004); Eckstein et al. (2007); French et al. (2004); Goodman et al. (2008); Hacek et al. (2010); Hayden et al. (2006);

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Rampling et al. (2001); Wilcox et al. (2003); Vonberg et al. (2008); Pina et al. (1998); Green et al. (2006). Indeed, Alfa et al. argue based on their study of a Manitoba hospital: “In conclusion, our data demonstrated that the use of an agent with some sporicidal activity for cleaning resulted in significantly reduced C. difficle spore levels in toilets of patients with CDAD [C. difficile–associated. disease] during non-outbreak conditions. Infection transmission within healthcare will remain problematic if the role of housekeeping remains undervalued and if they are not provided with adequate audit tools such as UVM [ultraviolet mark] to ensure sustained cleaning compliance” (2010: 268). 10. Berens (2002: 19). Many studies have shown that enhancing cleaning, together with a package of other reforms, can be a highly effective way of reducing hospital-acquired infections. For example, in a U.S. acute-care teaching hospital, the implementation of infection-control protocols and reforms—including enhanced cleaning—reduced C. difficile rate by 60% from 1990 to 1996 (Zafar et al. 1998). While the effects of each intervention remain challenging to parse out, some researchers also argue that they are mutually reinforcing; for example, greater attention and importance placed on cleaning can reinforce increased hand-washing among health care staff (Geller 1995). At the same time, many studies also now demonstrate that intensive and specialized cleaning methods can more effectively disinfect hospital environments and reduce the transmission of hospitalacquired infections (see sources listed in the previous note). 11. Wiener-Well et al. (2011). 12. When workers clean an area without properly disinfecting it first, they can spread pathogens across a wide area and actually increase, rather than decrease, environmental contamination (Fawley and Wilcox 2001; Barker, Vipond, and Bloomfield 2004, both cited in Murphy 2007: 18). 13. This is, of course, a perfect example of the kind of first-order thinking that Tucker and Edmonson (2003) explore in their California Management Review article “Why Hospitals Don’t Learn from Failures.” 14. Carling, Briggs, Hylander, et al. (2006). 15. Ibid. Subsequent educational interventions for cleaners were shown to improve the thoroughness of cleaning at these hospitals, especially of these overlooked high touch objects (ibid.). 16. Malik, Cooper, and Griffith (2003). 17. Davies (2010); Berens (2002). 18. Dancer (2008). 19. Cohen (2001: 9). CHAPTER 4

1. Klein (2007: 355). 2. These workers were often even harsher about the quality of work completed by their co-workers. Given the tendency for most people to avoid cognitive dissonance by viewing and describing themselves as good or doing a good job, it is striking that many support workers readily described the ways in which they were not completing high-quality work. 3. Leyne (2009a, 2009b) 4. Henry (2008: 5). 5. According to Pratt et al., “Transmission of microorganisms from the environment to patients may occur through direct contact with contaminated equipment, or indirectly as a result of touching by hands” (2007: S13). 6. Henry (2008: 4). Ensuring that bedpans are disinfected at high enough temperature and for enough time is a topic of discussion in the infection-control literature in the era of C. difficile.

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7. Vancouver Island Health Authority (2010); Canadian Broadcasting Corporation (CBC) News (2010a). 8. (Pollak 2004: 1). This research also included an environmental scan of the hospital over two twenty-four-hour periods in May and June 2004, as well as additional surveys and interviews with health care professionals at the hospital. The researchers also used the contracts and inspection material (5). 9. Ibid., 6. 10. Ibid. 11. Pollak (2004: 25). 12. Ibid., 24. 13. Ibid., 26. 14. Ibid., 37. 15. Ibid., 6–7. 16. Ibid., 43. 17. Ibid., 22. 18. Stanwick (2009: 35). 19. Ibid., 36. 20. McIntyre and Mustel Research, Ltd. (2002). This is not surprising because, based on their research on U.S. hospitals, Eileen Appelbaum and colleagues, industry studies scholars, report, “higher wages and staffing adequacy in departments are key management measures that reduce employees’ desire to leave their current employers” (2003: 78). 21. The average worker I interviewed had only 3.9 years’ experience in his or her current job, but it’s worth noting that the privatized companies had taken over providing these services only between five and seven years before the interviews. Yet privatization and outsourcing are the main reasons that many experienced workers no longer work in the hospital. 22. U.K. Department of Health (2008: 16). 23. These findings echo other research on the consequences of contracting out hospital support jobs in other countries. For example, research in Scotland revealed that contracted-out hospital cleaners received fewer hours of training and orientation than their in-house counterparts. In addition to the higher turnover rates among contract workers, these workers were also found to lack on-the-job mentors (Scottish Executive 2002, cited in Canadian Union of Public Employees 2009: 11). 24. Marjorie Griffin Cohen, political scientist, has detailed the many ways that hospital support work differs from the work of hotel room attendants, laundry workers, and other positions (Cohen 2001). 25. Boyce (2009); Boyce et al. (2008); Carling, Briggs, Perkins, et al. (2006); Carling and Bartley (2010); Carling et al. (2010); French et al. (2004). 26. Dancer (1999, 2008). 27. See Alfa et al. (2010). 28. Pollak (2004: 44). CHAPTER 5

1. The findings support earlier research on the deleterious consequences of cleaning and other hospital support jobs in the United Kingdom. According to Davies, “The House of Commons Health Committee (1999) warned: ‘The often spurious division of staff into clinical or non-clinical groups can create an institutional apartheid which might be detrimental to staff morale and to patients’. Twenty years ago, Collins (1988: 55) observed that in the pre-contract era ‘it was relatively easy’ to get additional cleaning done during an infection outbreak but that contracts ‘cannot readily be altered to respond to a change in infection hazard requirement, at least not until the task has been costed and allocated

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to a particular budget’. The Healthcare Commission found such examples of inflexibility when it investigated the outbreaks of C. difficile at Stoke Mandeville Hospital (in which thirty-eight patients died) (Healthcare Commission, 2006: 37)” (2010: 454). 2. Appelbaum et al. (2003). 3. Based on a study of an airport, Rubery et al. (2003) find that contracting out resulted in multiple employers and created a multiagency employment environment, which resulted in complexity and confusion when it came to the loyalty of employees, especially when institution wanted to control their work. They find this resulted in tension, conflict, confusion. The introduction of for-profit contractors into public health care systems may exacerbate the tension and fragmentation caused by outsourcing. According to Steve Davies, in the United Kingdom “the market approach operates on a different set of values and norms to that of the NHS [National Health Service] public sector ethos. It replaces public service with private gain, introduces personal accountability instead of collegiate responsibility and discretionary, individual remuneration in place of uniform and transparent pay and promotion structures (O’Toole, 1993; Hebson et al, 2003)” (2010: 452). 4. See also Koppel and Gordon (2012) on the importance of teamwork in hospital for patient safety. 5. Ibid.; Bradley et al. (2009); Lindberg et al. (2010); Pascale, Sternin, and Sternin (2010). 6. Pollak (2004); Murphy (2007). 7. Pollak (2004: 34). 8. Ibid., 36. 9. Ibid., 34. 10. Canadian Union of Public Employees (2009: 12). 11. Pollak (2004: 32). 12. Ibid., 31. 13. Ibid., 30–31. 14. Liyanage and Egbu (2006: 251). 15. A study of three Scottish hospitals found cleaners to be second only to nurses in terms of time spent with patients (Cumming 1992: 23, cited in Davies 2010: 454). 16. Pollak (2004: 39). 17. Messing (1998). 18. See, for example Rosenthal (2009); Gill and Reynolds (1999). Zullo and Ness (2009) found in an assisted survey of healthcare workers that privatization results in higher work stress and lower perceptions of reward. 19. UK Comptroller and Auditor General (2004: 14), cited in Murphy (2007: 29). 20. For example, Currie, Koteyko, and Nerlich find that, even though matron nurses in the United Kingdom were brought in to help address some of the teamwork and communication problems in hospitals with outsourced support workers, these nurses report difficulty in managing outsourced cleaners or the organization of cleaning work, even with the power to withhold payment to contractors for substandard performance. Based on interviews with nursing matrons at a hospital in the UK Midlands, they report: “The matrons interviewed for our study pointed out difficulties when describing their experiences of trying to manage cleaning. . . . Linked to their difficulty in managing cleaners on a day-to-day basis, matrons had no input into the way in which the cleaning workforce was organized. . . . In short, cleaners at ward level, over whom modern matrons attempt to exert control efforts, respond to their line manager who works for the private subcontractor rather than the hospital. This means that modern matrons may need to manage cleaning services indirectly through the hotel services department in the hospital, since hotel services managers can more effectively hold subcontractors to account. Such ‘arms length’

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management of cleaning services limits the impact of modern matrons upon infection control” (2009: 302–3). 21. The nature of the hospital is increased boundary blurring. “In addition, there is a certain amount of job enlargement on the part of health support staff, with the result that the distinction between their work and that of nursing staff is blurred at the edges. They provide social support to patients, by talking to them while on their rounds and assisting in various ways. This contact works both ways, with patients able to influence the cleaning (Armstrong et al., 2006: 14). Attending to patients’ needs is not part of a cleaner’s job description, but Grimshaw and Carroll (2008: 198) found that ‘it was considered by some as an inevitable part of the job’. They also noted that this ‘boundary blurring’ sometimes works the other way as well, with assistant nurses carrying out some cleaning tasks in bathrooms and patient areas (2008: 199)” (Davies 2010: 454). 22. Based on their study of two Montreal hotels, Seifert and Messing find that “The outsourcing of work previously conducted in-house can have significant impacts upon cleaners’ work, even if their own jobs are not outsourced. Thus, as Quinlan, Mayhew and Bohle (2001) have argued, outsourcing often leads to considerable changes in the ways tasks are carried out because the contracts with outside providers may not make explicit all of the necessary—yet often invisible and informal—aspects of the tasks as they were conducted in-house (cf. Messing, Chatigny and Courville 1998). At the same time, however, the hotel typically assumes that all parts of the newly outsourced tasks have, in fact, been addressed as before. The result is that many problems start to fall between the cracks” (2006: 563). 23. Rubery et al. (2002: 645). 24. Morgan (2011). 25. Pollak (2004). 26. Ibid., 45. 27. Dancer (2009); Dancer et al. (2010). 28. Stanwick (2009: 39). 29. Pollak (2004: 48). 30. Ibid., 49. 31. Power (1997). 32. Pollak (2004: 11). 33. Zuberi (2006). 34. One of the clearest indications of the desire by the managers of the Vancouver health authority to uphold the current outsourced service regime at all costs is their ignoring the request by their own ValueIn team to complete an annual independent audit of the outsourced support services. Instead, to save money, they have opted for “reciprocal” audits, where they compare inspection scores with other health authorities (Pollak 2004: 52). If the goal were to assess how the system is faring in the aftermath of outsourcing, they could easily compare inspection scores with the other British Columbia health authorities (such as the Northern or Interior Health Authority) or the Canadian health authorities that have not privatized their support services. Instead, the Vancouver health authority managers decided to restrict their comparison to a sample of other health authorities, such as the Calgary Health Authority and Fraser Health Authority, that have also privatized and contracted out their hospital support, often to the same multinational corporations (Pollak 2004: 52). 35. “As Entwistle (2005: 201) observes, ‘principals operating in a hierarchy have access to a greater range of instruments of control than do principals operating through markets.’ ” (Davies 2010: 458). 36. Pollak (2004: 5). 37. CBC News (2010b).

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38. Stanwick (2009: 39). 39. Ibid., 39–40; Carling and Bartley (2010); Carling et al. (2010); Dancer (1999, 2004, 2008). Aycicek, Oguz and Karci (2006) recommend using both adenosine triphosphate (ATP) bioluminescence and traditional microbiological swabbing and culturing based on their comparison of these tools to detect and improve surface hygiene in hospital kitchens in Turkey. Lewis et al. (2008) utilize this recommended combination of ATP and microbiological analysis at a 1,300 bed teaching hospital in the United Kingdom. They found a modified cleaning procedure based on best practice allowed them to achieve an even stricter pass/fail benchmark and improved disinfection. 40. According to researcher Janice Murphy, “In a UK study involving four hospitals, audit tools used to evaluate cleaning efficacy were compared. Visual assessments were not found to correspond with microbiological risk and were demonstrated to be a poor indicator of cleaning efficacy. Although 90 percent of the wards were assessed as being visually clean, rapid microbiological cleanliness testing with adenosine triphosphate bioluminescence (ATP bioluminescence) showed that 100 percent of the sites were not cleaned satisfactory and microbiologic sampling found that 90 percent of the apparently ‘clean’ environmental sites carried an unacceptable load of microorganisms” (quoted in Malik et al. 2003, cited in Murphy 2007: 38). 41. Vousden (2008b: 22). CHAPTER 6

1. Appelbaum et al. (2003: 83). Some of the findings from the Hospital Support Workers study on the impact of outsourcing on family life were presented in Zuberi (2011) and Zuberi and Ptashnick (2012). 2. Newman and Chen (2007). 3. Wider Opportunities for Women (2011). 4. Hochschild (2003) demonstrates that even as women enter the workforce, they continue to work a “second shift” at home, spending disproportionate time on child care, cooking, laundry, and cleaning. 5. Heymann (2006: 71). 6. As Angela Coyle, British sociologist, argues, “The family now appears to be under pressure as never before . . . and it is long working hours especially that are now regarded as the enemy of family life” (2006: 79). Research has identified both negative health and mental health effects of precarious work conditions (see for example, Ferrie et al. 1998). 7. Lino (1998), in Gilbert (2008: 76). 8. An extensive research literature—including Juliet B. Schor, economist, Born to Buy (2004); Benjamin Barber, Consumed (2007); and Joel Bakan, Childhood under Siege (2011)—reveals how children are systematically targeted by marketers and corporations from an early age to become consumers who can motivate, through guilt and other tactics, and encourage their parents to purchase them toys, clothes, and other trendy consumer items. 9. See Lareau (2003); MacLeod (2009). Research has linked involvement with extracurricular activities with better outcomes for youth. 10. Similar to other outsourced workers, they feel they have not been treated fairly by being contracted out and experience organizational injustice in terms of reduced wages, reduced benefits, and worse working conditions (Morgan 2011). 11. Cohen and Cohen (2004: 13). 12. As in many countries, the taxes for government-provided retirement benefits end up being regressive because they are collected on only the first $40,000–50,000 of annual income. So while low-wage workers pay the full combined federal and provincial/state proportion of their income, wealthy workers, whose earnings are above this cap, pay a

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lower proportion of their income for this benefit, with the highest earners paying the lowest proportion of their income. 13. In Canada, the percentage of employees with employer-provided retirement benefits is declining. This means that a growing proportion of seniors will have to depend on their own savings, remain formally employed through retirement, or use social safety-net programs to survive. 14. Strauss-Blashe, Ekmekcioglu, and Marktl (2000). 15. As part of the British Columbia labor code, employers are required to provide two weeks paid vacation after one year of employment to all employees. Without this legal mandate, it is possible these workers would receive less paid vacation time, especially in their first year on the job. 16. Philip et al. (2005); Weinger and Ancoli-Israel (2002). 17. Gold (2011); Institute of Medicine (2009). 18. Newman (2000: 296). 19. Dominguez and Watkins (2003) find that women living in poor neighborhoods were cautious about widening their social networks beyond family and close friends and that some expressed distrust of neighbors. 20. And that does not ignore the fact that these network connections can also work the other way to prevent the accumulation of resources, over the longer term, because they are reciprocal relationships (Stack 1997). Stack’s findings have been replicated by more recent studies of the urban poor (Newman 2000, 2006; Wilson 1996, 2009). 21. Sampson, Raudenbush, and Earls (1997). 22. Wilson (1996, 2009). 23. Newman (2000). 24. See Ritzer (2007). Outsourcing also contributes to growing income inequality, which in wealthy countries is associated with poorer general health and life expectancy outcomes as compared to more equitable countries (Kawachi and Kennedy 2002; Marmot 2005; Wilkinson and Pickett 2009). Employee perceptions of job security are also strongly associated with self-rated physical and mental health (Virtanen et al. 2002). 25. At the same time, higher wages can lead to hours being cut, which hurts workers’ take-home pay and exacerbates systematic understaffing. Dana Singh, a fifty-oneyear-old Indian housekeeper, says that, when privatized contractors are forced to pay higher wages and benefits, they react by cutting hours to save labor costs. “Even if our employer increase pay, the problem is that we got raise, and our hours reduced more than the [value of the] raise we get hourly. . . . Let’s say, for example, we just got a raise approved by union and the company contract. For example, they gave us forty more cents per hour. If they only give you forty cents per hour, the more hour they have taken away from the workers.” That shows how challenging it can be to make progress in an outsourced system. 26. Zuberi (2006); Yates (2009). 27. Zuberi (2006); Western and Rosenfeld (2011). 28. Milkman (2006: 12). 29. Richards et al. (2008). 30. See Lopez (2004b); Milkman and Voss (2004); Robinson (2000). CHAPTER 7

1. Häger et al. (2004). 2. Andriole et al. (2009), prostate cancer screening; Buys et al. (2011), ovarian cancer screening; Welch and Frankel (2011), breast cancer screening. In some cases, the screening may be causing harmful outcomes as a result of false positives, which cause patients to complete unnecessary and risky treatments.

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3. Canadian Committee on Antibiotic Resistance (2007), cited in Murphy (2007: 8). Based on an analysis of thirty reports, Harbarth, Sax, and Gastmeier (2003) estimate the potential to reduce nosomial infections by 10% to 70%, depending several factors, and conclude that at least 20% of all infections are preventable. 4. Infectious Diseases Society of America (2010). 5. Simon Tierney, a senior administrator of a health care–associated infectionreduction program for a U.S. state, puts the challenge into perspective: “We are trying to hit a moving target. It is not one sort of simple thing where the microbes don’t evolve, the patients don’t change. We take care of sicker patients who years ago would have had no chance of survival. That means we do more invasive things to them, there is more opportunity for them to become compromised and infected either with their own flora or with bacteria and viruses and fungi that we bring to them. Second, the microbes are adapting. They become drug resistant, they become more virulent. Third, it’s a global world. We import these people from all over the world, so some of the current challenges like Acinetobacter spp. are coming back from the war in the Middle East. Compounding the problem is the pipeline of new drugs . . . has been diminishing. So we have less in our armament and we have to focus more on prevention, we have to focus more on antimicrobial stewardship, we have to focus more on infection control. The bacteria adapt faster than we produce unless we’ve got good surveillance, unless we’ve got good management systems we are going to be two steps behind them.” 6. Canadian Union of Public Employees (2009: 1). 7. Brody (2008: F7). 8. Ibid.; Pronovost et al. (2006). “The recommended procedures are hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters” (Pronovost et al. 2006: 2726). 9. Brody (2008: F7). Pronovost et al. (2006) estimates that the Michigan Keystone Initiative reduced infections by approximately 66%. 10. Brody (2008: F7). According to another article in the Washington Post, “checklists may be one of the great medical innovations of recent years. Take the work of Peter Pronovost, an anesthesiologist at Johns Hopkins Hospital, rated one of the top 100 most influential people in the world last year by Time magazine. By implementing a checklist on the insertion and management of central venous lines with the help of Pronovost and his team, ICUs in Michigan hospitals reduced bloodstream infections to nearly zero” (Jain 2009: HE01). See also Gawande (2009: 38–39). 11. Gawande (2009: 159). 12. CBC News (2010b). According to this article, the Toronto General Hospital was a part of an eight country pilot study commissioned by the World Health Organization, which found checklist implementation reduced the post-operative mortality rate by nearly 50% (from 1.5% to 0.8%) and complications from 11% to 8%. 13. Silversides (2009a). 14. Ibid. 15. McCarter (2008: 31). 16. Kmietowicz (2000); McCartney (2009), both cited in Stanwell-Smith (2012). 17. The Globe and Mail reported in an editorial that, “In the United States, 18 states require hospitals to publish infection rates,” and urged that “Canada’s provinces should do the same.” (“Time to Take Superbugs Seriously” 2007: A24). 18. Priest (2008a: A1). The U.S. federal government has also stopped providing Medicare reimbursement to hospitals for treating certain preventable hospital-acquired infections and conditions (National Conference of State Legislatures 2008).

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19. Eggertson (2007). 20. Having recently completed a book on the problems with the public reporting, and particularly the ranking of schools on the basis of standardized test scores, I understand the concerns of some administrators and policymakers about the potential for distortions or other problems created by this kind of demand for institutional accountability. Yet given the life and death nature of this growing epidemic of health care–associated infections, the benefits in terms of preventing infections and suffering and of saving lives clearly outweigh the negative aspects of monitoring and reporting infection rates. Pennsylvania was the first U.S. state to require the reporting of hospital-acquired infections. What the hospitals found when they began monitoring infection rates was shocking: “More than 30,000 people contracted infections in 2006 while undergoing treatment at hospitals in Pennsylvania, according to a state report to be released today. While the number of infections is eye-popping, most patients make it through hospital stays without experiencing the problem. About nineteen patients in 1,000 get so-called hospital-acquired infections. Still, as the Pennsylvania Health Care Cost Containment Council report reveals, hospital-acquired infections are costly in both human and financial terms. Patients who got infections remained in the hospital an average of nineteen days, compared with fewer than five days for those who did not do so. Patients with infections wracked up hospital charges averaging nearly $176,000, compared with less than $34,000 for other patients. Urinary-tract infections were the most common, affecting 13,635 patients. Nearly 4,000 patients contracted gastrointestinal infections, and there were an additional 3,326 cases of pneumonia” (Goldstein 2008: B01). In one study at three U.S. hospitals, expanded surveillance for MRSA reduced MRSA infections at hospital admission and thirty days subsequent to patient discharge (Robicsek et al. 2008). Another study at another U.S. hospital found that active surveillance for VRE on patient admission to the ICU was a cost-effective method to prevent colonization and bacteremia (Shadel et al. 2006). Van Rijen and Kluytmans (2009) find that the aggressive search and destroy policy at a Dutch hospital from 2001 to 2005 reduced hospital costs and saved lives. 21. Murphy (2007: 22, 35). 22. Priest (2008a: A1). Of course, the measuring and tracking of hospital-acquired infections and related deaths are not uncomplicated. 23. Graves (2004); Gould (2006); Perencevich et al. (2003). A UK study estimated that infected patients, controlling for other related factors, stayed in the hospital an extra eleven days and required approximately three times the treatment and discharge costs as uninfected patients (Plowman et al. 1999). 24. Jacobs (2011). 25. Graves, Halton, and Lairson (2007). For example, the MRSA search and destroy policy in the Netherlands has effectively reduced the rate of MRSA infection and dramatically reduced costs (Nulens et al. 2008). 26. Stanwick (2009: 32). 27. Pascale, Sternin, and Sternin (2010); Bradley et al. (2009); Lindberg and Clancey (2010); Lindberg et al. (2009, 2010). According to Marra et al. (2010) in an Infection Control & Hospital Epidemiology article, a positive deviance approach including bimonthly staff meetings focused on hand hygiene, helped sharply reduce the hospital-acquired infection rate in an ICU of a city hospital. 28. Gardam (2007: A23). 29. Priest (2007b: A6). 30. Quoted in Silversides (2009a: 573). 31. Geller (1995). 32. For example, one study of a Baltimore hospital found environmental contamination responsible for infecting two health care workers with MRSA (Johnston et al. 2006).

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33. Bridges et al. (2003); Hota (2004); Kramer, Schwebke, and Kampf (2006), all three cited in Murphy (2007: 11); Sehulster et al. (2003). 34. Murphy (2007: 17). 35. Ibid., 30, 34. 36. Ibid., 34. 37. Currie, Koteyko, and Nerlich (2009). 38. Jeanes (2005: 35), cited in Murphy (2007: 30). 39. Canadian Union of Public Employees (2009: 12). 40. Chen (2003), cited in ibid., 12–13. 41. Some of my future research will focus on leading a multidisciplinary team to complete a mixed-methods study of how to improve infection control in Vancouver and Toronto-area hospitals. The goal of the research will be to generate important insights for reform through in-depth interviews and consultations with a wide-range of health care professionals and leaders. In British Columbia, a commission could consider whether some services should be brought back in-house and, more generally, ways that infection control and patient safety could be improved. I support Pollak’s recommendation that an “audit should be wide-ranging, descriptive, and analytic” and “that survey and qualitative data be collected from personnel at all levels of the system and in all relevant job categories, public and private employees alike. The views of patients and family members should also be solicited” (2004: 55). 42. Canadian Union of Public Employees (2009: 2). 43. McCarter (2008: 15–16). 44. Ibid., 18. 45. Evidence from programs designed to prevent MRSA contamination and transmission in hospitals in the Netherlands suggests that the most important policies include physically isolating and decolonizing MRSA patients and health care workers as well as promoting frequent hand-washing and disinfection of facilities (Vos 2007). 46. Ibid. 47. O’Connell and Humphrey (2000: 255). 48. The research on infection control points to the design and layout of hospitals as one factor in the transmission and outbreaks. Another factor is patient mobility within the hospital. One study by Jusot et al. (2003) using multivariate statistical analysis identified several factors linked to the higher rates of hospital-acquired diarrhea, including patients’ mobility outside of their room, open patient doors, having more than twenty beds per ward, and nurse understaffing. 49. BBC News (2004). 50. Hurley and Gindin (2012) cite several studies that detail the potential longer-term cost savings of improved infection control. 51. Bascetta (2008), McCaughey (2008). 52. See the Safe Patient Project.org (2013) by the Consumers Union: http://safepatientproject.org/ (accessed February 9, 2013). 53. Harrington (1997 [1962]: 174). 54. According to David Macarov, professor of social work, “the problem is not so much a lack of work as such—it is a lack of decently paid, full-time, long sustained employment. Without that, there will always be many people who work but are nevertheless poor” (2003: 34). Kalleberg (2009) describes the rise of precarious work in the United States since the mid-1970s. 55. Wilson (1996, 2009). This argument is eloquently supported by Linda McQuaig, The Wealthy Banker’s Wife (1993). 56. In the longer term, investments in education, training, and lifelong learning— perhaps modeled on the Danish “flexicurity” system—would help more workers secure jobs in emerging fields such as the green economy.

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57. Reforms to the tax system can start from the provincial and state level, and scale up to the federal government. Historically, the expansion of the Canadian universal health insurance system from the province of Saskatchewan to the recent national expansion of the innovative state-level approach to improving health care access from Massachusetts to the United States, demonstrates that there is no reason to wait for change at the national level. Indeed subnational reforms often percolate up to the national level as coalitions build momentum and strength from local successes and topple conventional wisdom. 58. Ehrenreich (2008: 231–32). 59. Luce (2004); Rhee and Zabel (2009). 60. Wills (2001, 2006); GLA Economics: The Living Wage Unit (2005). Research on hospital cleaners and other support workers in London found increases in job satisfaction, quality of life, and reduced hardships associated with increased hourly wages and work conditions secured through a living wage campaign (Sokol et al. 2006). 61. Given the current post-Olympics economic climate and cutbacks in the province, it is clear that the contract negotiated after the living-wage campaign was an important success for hospital support workers. Currently, most public employees are facing wage freezes when their contracts expire because the economic crisis, reductions in provincial income tax rates, and increasing health care costs have reduced the available resources. 62. Bakan (2004: 161.) 63. Richards et al. (2008). 64. In the past several decades, many advanced countries have continued to massively increase expenditures for military and corrections while at the same time implementing tax cuts for wealthy corporations and individuals. 65. While advances in technology help explain the redistribution of power toward employers in the manufacturing sector, a more complex political-economic dynamic underlies the similar trend in the service sector. Sociologists should play a central role in explaining the interplay of forces that are reshaping economic life from local, vibrant communal capitalism toward franchise capitalism. 66. Greenhouse (2007: 178). 67. Zuberi (2006), Yates (2009). 68. Advancing skills and training is often difficult for low-income workers because they face significant financial barriers and time constraints. Bonnie Kruja, housekeeper, is ambitious and hopes to move up to a higher-ranking health care position. She completed a licensed practical nurse (LPN) training course that she somehow managed to squeeze in between her two jobs and caring for her three children. “It was stressful,” she says. “I have to do my homework, and next morning I have to go to work, not only work, then I came home clean up the house, cooking, and the kids. Thank God it’s finished! I’m so happy [laughs].” The course cost $3,500 and took six months to complete. Yet the payoff in terms of wages and benefits is substantial, especially because labor shortages exist for many of these positions. Lifelong educational and training opportunities that help support workers realize their objectives and potential will help fill important job positions, improve the human capital of the labor force, and improve workers’ life satisfaction. At the same time, not everyone can or even wants to go back to school to get a better job. Many older support workers, for example, said that they feel it was too late for them to return to school or train for a new job. Resigned to their current positions, they base their hopes for a brighter future on their children’s success. 69. My research contributes to our understanding of the impact of privatization and neoliberal government policies and practices. It also builds on Canadian research by Armstrong (2001) on nurses and Armstrong et al. (1994) on the impact of privatization in Ontario on health care workers, and broader neoliberal reforms on healthcare (Armstrong and Armstrong (2003). 70. Herbert (2007).

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Index

A. Baumannii, 5, 23, 136n28 accountability, lack of, 121 accreditation, hospital, 109 Acinetobacter baumannii. See A. Baumannii Acinetobactoer spp., 5 adenosine triphosphate (ATP)-bioluminescence, 42, 143nn39–40 Adler, Peter, 130n47 Adler, Patti, 130n47 administrators, hospital control over conditions, 17, 76–79 cost control, 114 opposition to reporting HAI, 109 role in prevention, 112 use of audits, 67 aging population, 26, 113 alcohol-based sanitizers, 23 All Our Kin (Stack), 101 American Economic Review, 15 American Hospital Association (AHA), 26–27, 128n41, 129n41 American Journal of Infection Control, 38, 138n4 amputations, 3 Aneesh, A., 130n47 Applebaum, Eileen, 133n73, 140n20 appreciation, lack of, 74 Aramark, 13 audit failure to create required changes, 52, 67, 76–80 lack of sufficient number of, 45, 62 limited consequences of failing, 38, 121 need to enhance, 113, 124, 138n4, 139n9, 142n34, 147n41 as retaliation, 65 austerity, 26. See also budget cuts Australia, 116, 133n74 Bakan, Joel, 121, 143n8 Barber, Benjamin, 143n8 bed occupancy. See overcrowding bedpans, 26, 51–52, 76, 139n6 bed sterilization, 4 Betrayal of Work, The (Shulman), 134n80 Biais, Bruno, 15

Bill 29 legislation, 8 BMC Medicine, 5 Born to Buy (Schor), 143n8 Boston’s Carney Hospital, 5 boundary blurring, 142n21 breaks, skipping, 47 British Columbia Center for Disease Control (BCCDC), 52 British Columbia Government and Service Employees’ Union, 8 British Columbia labor laws, 92, 103, 144n15 budget cuts consequences of, 137n42 hospitals, 26–27, 114–15, 137n55 government health spending, 102, 148n61 pressure to outsource, 122, 133n68 to support staff, 6, 19 burn, 34 California Management Review, 139n13 call centers, 15, 68 Canadian Centre for Policy Alternatives, 132n55 Canadian Charter of Rights and Freedoms, 131n48 Canadian Medical Association Journal, 6 carbaperiem-resistant Enterobacteriaceae (CRE), 24 caring for children, 30, 85–89, 93–95, 98, 101 for parents, 30, 87, 93, 96–97, 101 Carling, Philip C., 5 casual, on-call workers, 37, 42, 57, 98 catheter infections, 107–8 C. difficile consequences of infection, 2–5, 136n18 infection rates, 12, 136n15 outbreaks, 25, 27, 51–52, 79, 115, 141n1 prevention, 108–9, 139n9 spores, 44 toxic strains, 22–23, 136n20 Cedars-Sinai Medical Center, 110 Center for Disease Control of Taiwan, 112 challenges saving money, 85, 91 challenging schools, 100

175

176

INDEX

Checklist Manifesto, The (Gawande), 13 checklists, 4, 107–8, 145nn8–12 chemicals, mixed improperly, 52 Chen, Victor Tan, 86, 87 Chicago Tribune, 38 child care, 85, 87, 117, 121 Childhood under Siege (Bakan), 143n8 child poverty, 116 children activities, can’t afford, 88–89 living in different country, 93, 95 China, 29 citations, 6 “Clean Care is Safer Care”, 4 cleaners invisible, 28, 74 undervalued, 5, 28, 34, 49, 60, 66, 74, 106, 138n61 clean the lines, 31, 56 Clostridium difficile. See C. difficile coalitions, 117, 148n57 Code Green (Weinberg), 129n44 Cohen, Marjorie Griffin, 46, 128n41, 140n24 collective agreements, 8, 47, 92, 131n48, 135nn89–90 communication, 17, 20, 53, 64, 68–70, 72, 75 community efficacy, 101 community infections, 4, 25, 27 complacency, 111 compliance, fear based, 110 complications, 22, 105–6 Compulsory Competitive Tendering (CCT), 14 confusion, 17 consequences failure to pass inspection, 77 of improperly mixing chemicals, 52–53 of inadequate supplies, 38 of poor quality work, 62, 105, 121, 139n12 Consumed (Barber), 143n8 Consumers Union, 115 contagious patients, 32–34, 40–41, 58, 74 contagious workers, 65–66 contract flipping, 15 control, 17, 20, 38, lack of, 79 loss of, 55, 67, 76–77, 122, 140n1, 142n35 cooperation. See teamwork co-pays, challenges paying, 91 corporate lobbying, 14, 16 Corporation, The (Bakan), 121 cost of living, 87 costs of diagnostic services, 26 of extended patient stays, 12

of health care-associated infections, 2, 113, 127n10, 146n20 of legal settlements, 14 of prescription drugs, 26 savings from prevention, 14, 17, 21–22, 26, 131n51, 132n67 savings from reform evidence, 107–10, 147n50 Coyle, Angela, 143n6 crime, 85, 99–100 crowding, 86, 89–90 Culinary Workers Local 226, 122–23 cultural capital, 88 Dancer, Stephanie, 5 Davies, Steve, 12, 137n42, 140n1, 141n3 death, from health care-associated infections, 1–3, 12, 21–22, 52, 112 debt, 16, 82, 87, 89, 96 deep clean, 5, 23. See also specialized cleaning procedures Denmark, 17, 22, 113, 135n90, 147n56 dental care, challenges accessing, 91 development of new antibiotics, lack of, 25, 107, 145n5 diarrhea, 31 Dirty Pretty Things, 106 dishwashing, 28, 33, 49 disinfection, 25, 28, 31, 37, 53, 60, 111 disinvestment. See budget cuts disposal, proper, 20 disruption, 7, 13, 24–25 to cleaners, 31 doctor’s note, 47, 66 Dodson, Lisa, 94 double shift. See work hours Earls, Felton, 101 E. coli, 23–24 economic restructuring, 15, 116, 122, 148n65 economic security, 16, 29–30, 87, 115, 130n47, 131n47, 144n24 Edin, Kathryn, 88 education and training opportunities, 148n68 education, early childhood, 117–18 Ehrenreich, Barbara, 30, 119 Emergency Room (ER), 26–27, 31, 45, 52–53 employee commitment, 129n41, 141n3, 141n18 employee turnover, 54, 57, 70, 78, 140nn20–21 emotional challenges, 33, 46, 73–74, 93, 95 environmental contamination, equipment, 135n3, 139n5

INDEX

high touch surfaces, 135n9, 136n9 and hospital-acquired infections, 26, 51–53, 111, 136n28, 146n32 infected patient rooms, 70 limits of visual inspection, 143n40 shortcuts and, 41 support workers contributing to, 36 equipment, 7, 36 contaminated, 22, 26, 52–53, 135n3 ER, 28, 106 Escherichia coli. See E. coli exhaustion, 82–83, 97–98, 100 experience, years of, 55–56 exposure to harsh chemicals, 32, 47–48 to pathogens, 32, 33, 47–48, 61, 111 to toxic waste, 61–62 extended hospital stays, 1, 3 extracurricular activities, 143n9 facility renovation, 114 factors affecting HAI, 7, 17, 22, 24, 38, 41, 147n48 Fair Labor Practices, 121 fairness, sense of, 143n10 family crises, 94–95 family occasions, miss, 98–100 Farr, Barry, 38 favoritism, 64 feces, 53, 76. See also human waste disposal Finland, 130n44 First Call, 120 flexicurity, 147n56 floor washing, 31 France, 136n30 franchise capitalism, 102, 148n65 franchising, 6 Fuller, Sylvia, 134n86 future research directions, 147n41 garbage bags, heavy, 31, 33, 48, 59, 61 Gardam, Michael, 110–11 Gawande, Atul, 13 Germany, 4, 13, 133n76 GISA, 136n30 global economic crisis, 116 globalization, 102, 123, 130n47 and HAI risk, 24, 145n5 Globe & Mail, 110–11, 145n17 Glycopeptide-intermediate Staphylococcus aureus. See GISA Gordon, Suzanne, 129n44 gray areas, 75–76 Great Risk Shift, The, 130n47 Greece, 24, 136n28

177

H5N1 “avian” flu, 24 Hacker, Jacob, 130n47 hand-washing effectiveness, 4increasing rates of, 20–21, 25, 110–11 limits of, 15, 23 as prevention, 57 hardship, 16, 17, 29–30, 82–91 Harrington, Michael, 115 Healthcare Associated Infections Surveillance in BC, 11 health care sector, 7 health consequences, workers, 16 heat, inadequate, 82–84 Heat Wave, 101 Hemolytic-uremic syndrome (HUS), 23 hepatitis B, 46 Heymann, Jody, 87 high poverty neighborhoods, 99–101, 118, 144n19 homelessness, 90 hope for a better life, 29–30 hopelessness, 85, 91 hospital organization, 19–20, 28, 55, 67, 71, 74, 141n8 restructuring, 7, 26, 129n41, 129n44 Hospital (Salamon), 27, 28 hospital-acquired infections (HAI) complex causes, 12–13, 17, 22, 51–52, 111, 124 hospital cleaner compared to home housekeeper, 30 compared to hotel housekeeper, 8–9, 78, 80, 105–6, 142n22 compared to other industrial clients, 128n41 compared to private care facilities, 29 compared to similar jobs, different institution, 89 hospital design, 113–14, 147n48 Hospital Employees’ Union (HEU), addressing grievances, 65, 76 challenging outsourcing, 102 improving wages and benefits, 103, 131n48 legally challenging outsourcing, 14–15, 133n72 and living wage movement, 120–21 representing support workers, 8–9 House, 28, 106 housing issues, 85 human immunodeficiency virus (HIV), 21 human waste disposal, 76 hydrogen peroxide vapor, 26, 60 hygiene, 19, 21–22, 25, 30–31, 53

178

INDEX

Iceland, John, 130n47, 131n47 ICU, 13, 31, 46, 83, 135n6, 136n30, 146n20, 146n27 ideology, 15, 78 importance of work, 34–35, 56 incentives, 36–38, 42, 49–50, 62, 72, 98, 114 India, 29 inequality consequences of, 130n47 gender, 16 increasing, 15–18, 81, 102, 115, 119, 123 mobilizing against, 117 role of context, 118 role of outsourcing, 134n78, 144n24 Infection Control & Hospital Epidemiology, 146n27 Infection Prevention and Control (IPAC) Nurses, 112 infection statistics British Columbia, 11–12 Canada, 2, 12, 22, 24, 108, 135n5 UK, 12, 108 U.S., 2, 6, 21–23, 38, 107–8, 127n13, 136n15 Norway, 22 Infectious Diseases Society, 107 infestation, 82, 85, 90 infrastructure investment, 118 injuries on the job, 32–34, 46–48. See also workplace health and safety inspection. See audit institution culture change, 5, 17, 63 involvement in the community, 30, 87, 101, 124 Ireland, 79 Israel, 38 job ladders, 123 job satisfaction, 90, 141n18 job security, 102 job tasks, 27, 30–34, 53, 56, 106, 142n21 Klebsiella pneumoniae, 24 Klein, Naomi, 133n68 Klinenberg, Eric, 101 labor policies, 103, 117, 124 Lancet Infectious Diseases, 5, 27, 136n32 language barrier, 53–54 L.A. Story (Milkman), 102, 138n58 leadership development, 103–4 legal challenge, 133n72 claims, 127n12 expenses, 14 settlement, 14

Lein, Laura, 88 Libman, Michael, 23 living wage, 9, 16, 30, 115, 117 campaigns, 103, 119–20, 138n58, 148nn60–61 Living-Wage Certification, 121 local communities, forces undermining, 101–2 supporting, 118 logic of capitalism, 122 low-road service-sector jobs, 7, 15–16, 123, 125 Macarov, David, 147n54 Making Ends Meet (Edin and Lein), 88 making ends meet, challenges of, 9, 16, 29–30, 81–92, 100, 131n47 marketing to children, 143n8 material, high contact surfaces, 114 McKenna, Maryn, 137n37 McQuaig, Linda, 147n55 media coverage, 114–15 medical errors, 97, 98 Methicillin-resistant Staphylococcus aureus. See MRSA methodology, 8–9, 127n1, 131nn53–54 Michigan Keystone Initiative, 145n9 middle class, shrinking of, 122, 124 Milkman, Ruth, 102, 138n58 minimum wage, 116, 119 missing class, 87 mold, 84 monitoring, 113 Moral Underground, The (Dodson), 94 mortgage interest tax deduction, 118 MRSA consequences of infection, 1–2 infection rates, 11–12, 21, 146n20 prevention of, 4–5, 26–27, 32–33, 108, 113, 147n45 proper signage, 69–70 vectors of transmission, 111, 135n9 multidrug-resistant Acinetobacter (MDR), 24 multiple jobs financial necessity, 29–30, 82 and lack of community involvement, 100–101 and lack of time for children, 85–89 stress associated with, 9 Murphy, Janice, 143n40 Nanaimo General Hospital, 51–52, 79 NAP1 strain, 22 NDM-1 gene, 136n32 needlesticks, 32. See also workplace health and safety

INDEX

negotiations, 15 neoliberal policy reform, 134n78, 148n69 Netherlands employment policy, 17, 133n76, 135n89 reforms reducing HAI, 4, 106, 147n45 search and destroy, 113, 146n20, 146n25 networks, dependence on, 144n20 New Delhi metallo-β-lactamase 1 gene. See NDM-1 gene New Economics Foundation, 128n32 New England Journal of Medicine, 5 Newman, Katherine S., 86–87 New York State Department of Health, 108 New York Times, 28 New Zealand, 2, 29 Nickel and Dimed (Ehrenreich), 30, 106, 119 Nightingale, Florence, 125 non-standard work hours, 97–98, 100 norovirus, 5, 24, 52, 79, 124 Northern Ireland, 17 Norway, 22, 106 nurses barriers to teamwork, 74–76 communication with cleaners, 68–71 and infection control, 114, 141n20 interactions with support staff, 20, 58, 112 perceptions of cleaning quality, 53–54 Nursing against the Odds, 129n44 Occupy Movement, 117 Ontario, 108–9, 127n12, 129n44 operating room. See OR OR, 13, 31, 40–41, 105 outbreaks, 7, 22, 25, 43, 52, 108, 111, 115, 122, 141n1 outsourcing reasons for, 13–15, 28, 122, 130n46, 131n51, 132n67, 133nn74–75, 135n89 trends, 128n37 overcrowding, 7, 10, 16, 22, 26, 27, 44, 113 overtime. See work hours overuse of antibiotics, 4, 21, 25, 110 overworked consequences, 19, 47, 49, 53, 62 lack of adequate staffing, 12, 37 too many tasks for time, 10, 33–34, 41–44, 59 paged, 31, 53, 64 pan-drug resistant gram-negative bacteria, 24 part-time hours, 29, 144n25 patient interaction, 73–74, 138n61, 141n15, 142n21 isolation, 27, 40, 147n45

179

room sharing, 27 stay, length of, 146n20, 146n23 turnover, 27 wait times, 26 Pennsylvania, 146n20 Perotti, Enrico, 15 personal protection packs, 108 Philippines, 29–30, 81–82, 93, 95, 100, 120, 137n56 physical health determinants of, 93, 97 poor, 91–92 physical strain, 33–34, 44, 48, 97 Pickett, Kate, 130n47 policy reforms, 115–16, 148m57 political will, 114–15, 125 Politics and Policy, 12 Pollak, Nancy, 72, 78 poor quality work and audits, 78 causes of, 10, 17, 97, 122, 128n40, 132n61, 139n2 consequences of, 19, 22, 51–54 lack of adequate staffing levels, 42, 142n22 lack of adequate supplies, 37–38 lack of skills and training, 55–61 patient interaction, 72–75 poor supervision, 64 rushing, 44–45 positive deviance, 68, 110, 146n27 Poverty in America (Iceland), 131n47 poverty line, 16, 87–88 power shift, 122, 148n65 pneumonia, 3 precarious work, 15–16, 29, 55, 81, 134n78, 147n54 precautions, 57–60, 69–70, 79 limits of, 2 Presser, Harriet, 130n47 prevention, 28, 109, 113–14 prevention, importance of, 106, 113 private rooms, 109 privatization, 13, 14, 134n83, 148n69 profit extraction, 102, 134n80 and incentives, 36–38, 49–50, 55, 62, 72, 114 lack of, 133n67 motive, 74, 77, 121 and staffing levels, 42 and turnover, 62 Pronovost, Peter J., 107, 145nn8–10 protective gowns, 57, 59 public outrage, 112

180

INDEX

qualifications, lack of proper, 7, 17, 54 quality of life, 16–17, 130n47 Quebec, 22, 109, 136n18, 142n22 Raudenbush, Steven, 101 recruitment and retention challenges, 11, 54–57 job fairs, 54 rectal thermometers, 108 reform to address hospital-acquired infections, 4–5, 21, 106–7, 110–14, 123, 147n41, 147n45 effectiveness, 4–5, 21, 145n3, 145nn9–10, 146n20, 146n25 additional cleaner, 5 enhanced disinfection, 4–5, 128n25, 139nn9–10, 143nn39–40 ward housekeeper, 75 matron nurses, 141n20 withholding payment, 145n18 search and destroy, 146n25 relationship building, 70–71, 74. See also social isolation remittances, importance of, 30, 95–96 repetitive stress and strain injury, 33, 47–48 resistant infections, 4, 20–24, 145n5 retirement, 84, 143n18 reversing outsourcing, 17 risks exposure to contagious pathogens, 34 of getting a hospital-acquired infection, 2–3, 17, 52, 146n20 previous bed occupant infected, 5, 23, 128n31 of resistant infection, 22–23, 105–7, 135n6 of serious health consequences, 12, 38, 127n13 role of the state, 116 Rubery, Jill, 141n3 rushing busy periods, 40–41 to complete job tasks, 31, 33, consequences of, 44–47, 64 Safe Patient Project, 115 Salamon, Julie, 27–28 salmonellosis, 46 sample characteristics, 131n54, 137n56 Sampson, Robert, 101 sanctions, weak, 38, 77 SARS, 24, 112 savings from reform, 107–8

scabies, 46 Scandinavia, 4 Schor, Juliet B., 143n8 Scotland, 17, 127n12, 140n23, 141n15 Scott II, R. Douglas, 127n10 screening, 22, 113, 144n2 scrubs, 39 search and destroy, 22, 113, 146n20 second shift, 30, 87, 143n4 Service Employees International Union (SEIU), 6 severe acute respiratory syndrome. See SARS shift scheduling, 31, 97–98, 100 Shipler, David, 16 Shock Doctrine, The (Klein), 133n68 shortcuts. See skipped steps short staffing. See understaffing short-term emphasis, 114 Shulman, Beth, 134n80 sick days, 11, 34, 47, 65–66 denied use of, 92 lack of, 124 signage lack of proper, 70 indicating infection, 108 single parent, 33 skills required, cleaning, 26, 29, 54–55, 122, 148n68 skipped steps, 31, 39–46, 57 sleep deprivation, consequences of, 97–98 Social Accountability Standards, 121 social capital, 101, 118 social cohesion, 101 social exclusion, 18 social isolation in community, 11, 30, 88, 100–101 isolation at work, 68, 71–72 social movement unionism, 103, 120, 123, 138n58, 148n57 social policies, 28, 115–16 social safety net, 116 social spending, 116, 119 social value, professions, 128n32 Society for Healthcare Epidemiology of America, 38 Somalia, 29 source countries, 29–30 Spain, 17 specialized cleaning procedures, 26, 31, 42, 55, 60, 111, 143n39 specialized roles, 28, 55

INDEX

Spirit Level, The (Wilkinson and Pickett), 130n47 spores, 22–23 Sri Lanka, 29 Stack, Carol, 101 staff contagious, 11 as vectors of infection transmission, 38–39, 51, 58, 60, 69–70, 139n12 Standing, Guy, 130n47 Stanwick, Robert, 36, 54–55, 79, 110, 136n18 statistics, mandatory reporting, 109, 145n17, 146n20 Stinson, Jane, 8 St. Paul’s Hospital (Vancouver), 27, 32, 53, 68–69 St. Michael’s Hospital (Toronto), 4 strain on marriage, 100 stress, 10, 17, 33, 41–46, 82–86, 91, 128n40, 141n18 strike, 133n72 Superbug (McKenna), 137n37 supervision, 8, 17, 20, 94–95 discourage communication with others, 71–72, 141n20 lack of proper, 57 by pager, 68–69 poor quality, 62–66 reprimands, 61, 95 threat of dismissal, 76 super-spreaders. See staff supervisor turnover, 62–63 supplies, inadequate, 10, 36–39, 53, 56, 77, 138n6 Supreme Court of Canada, 131n48 surgery, 1, 13, 30–31 surveillance challenges, 146n2 emerging threats, 24 importance as reform, 5, 21–22, 109, 113 and reporting, 80, 145n17 trends, 11–12 Sweden, 22, 130n47 targets, 109 tax credits, low-income, 88, 116–17, 119, 121 tax policy, 118, 143n12, 148n57 teamwork, 53, 67–68, 72–75, 112, 123, 141n20. terminal cleaning, 31, 46, 64, 78 Time, 145n10 time, importance of predict and regulate, 101 time squeeze, 97–98, 101, 148n68

181

Tim Horton’s, 110 training, 7, 17, 26, 30, 37, 129n41 barriers to skill enhancement, 148n68 co-workers, on the job, 58–59 inadequate, 10, 17, 28, 48, 52–63, 78, 122, 140n23 no control after outsourcing, 77, 79, 141n20 and professionalization of support workers, 4, 30, 55–56, 111, 122–23, 137n56 supervisors, 63 transmission, 21, 24 transparency, 77, 132n65, 141n3 trends of hospital-acquired infections, 11–12, 21–24, 108, 132n58, 135n5 more complexity and resistance, 2–3, 13, 22–24, 145n5 turf wars, 74 Turkey, 143n39 UK audits and inspection, 77, 79, 135n9, 143n39 Department of Health, 56 employment trends, 130n47 HAI trends, 12–14, 22, 132n61, 137n42, 141n23 Health Protection Agency, 3 living wage movement, 119, 121, 148n60 media coverage of HAIs, 114–15 National Audit Office, 5 National Health Service (NHS), 13–14, 75, 141n3 privatization and outsourcing, 132n67, 138n6, 140n1, 141n1, 141n3 reforms to reduce HAIs, 5, 75, 112, 135n6 risks of infection, 2, 113 social value of professions, 128n32 ultraviolet (UV) radiation, 26, 42, 60, 79–80 marks, 139n9 underreporting of HAIs, 3 understaffing causes of, 17, 37, 55 consequences for quality of work, 10, 27, 36, 40–43, 53, 128n40 consequences for workers, 43–47 unemployment insurance, 116, 119 unidentified infection, 27 uniforms, 38–39 unions, 28, 102–4, 117, 122–23, 133n78 UNISON, 13, 119 United States. See U.S. universal health insurance, 28

182

INDEX

union organizing rules, 117 United Nations Declaration of Human Rights, 117 universal social programs, 115–16 University of Pittsburgh Hospital, 4 unpaid overtime, 58 urine, 31, 76. See also human waste disposal U.S. antibiotic resistance, 24 audits and inspection, 77, 138n4 Centers for Disease Control, 2–3, 21, 24, 127n10 environmental contamination, 42 HAI trends, 1–6, 38, 127n13 hospital outsourcing, 128n37 MRSA, 21–22 number of surgeries, 13, policy reforms, 137n55, 148n57 precarious work trends, 15–16, 87, 134n78, 134n80 reforms to address working poverty, 117–19, 122–24, reforms to reduce HAI, 106–15, 139n10, 145nn17–18, 146n20 risks of infection, 26–28 vacation, 82, 94, 96 vacation days, denied use of, 93 vancomycin-intermediate/resistant Staphylococcus. See VISA/VRSA vancomycin-resistant Enterococcus. See VRE Vancouver Coastal Health (VCH), 14, 53, 121, 133n71 Vancouver Island Health Authority, 54–55, 79, 110, 136n18 Victoria Times Colonist, 52 Vietnam, 29 violent patients, 32 VISA/VRSA, 4, 23–24 visual inspection, 42, 43, 77, 79, 138n4, 143n40 vomit, 31–32 VRE, 4, 12, 23, 33, 146n20

wages and benefits attracting and retaining workers, 7, 42, 55 consequences of low wages, 100–103, 131nn47 cuts to, 8, 29–30, 83–93, 128n40, 134n86, 137n57, 144n13 increases, 112, 116–17, 131n48 living wage campaign, 120–24, 148n60 paid sick days, 65 poverty, 16 unions, 15 Wales, 17 ward closure. See disruption. ward housekeeper, 75 Washington Post, 145n10 Wealthy Banker’s Wife, The (McQuaig), 147n55 Weinberg, Dana, 129n44 Wider Opportunities for Women, 87 Wilkinson, Richard G., 130n47 Wilson, William J., 101, 116 work conditions, 30, 33–34 worker’s compensation claim, preventing, 49–50 denying, 49–50 work hours, 16, 45 Working Poor, The (Shipler), 16 workplace health and safety coming to work sick, 65–66 denying workers compensation claims, 49–50 emotional health, 33, 46 exposure to pathogens, 11, 53, 57–58, 61, 69–70, 75, 132n57 injury and illness, 9, 32, 34, 47–49, 129n44, 130n45, 138n60 physical exhaustion, 43, 97, 128n40 risk of accidents, 10 too rushed to work safely, 45 stress, 31 World Health Organization (WHO), 1–2, 4