The Rise of Hospitals, the Decline of Healthcare

In addition to flyering, surveying, holding actions, events and other on the ground workplace and community organizing, members of Florence Johnston Collective (Flo Jo) read articles about health care and organizing every week.  Recently, thanks to a tip from Seattle-based Black Orchid Collective, a member of whom maintains a great blog, Diary of a Disparaged CNA (which is also full of great writing), we read the article “The Proletarianization of Nursing” by David Wagner.

The “Proletarianization of Nursing” covers the era of transformation of the practice of nursing from private duty to hospital nursing.  “Proletarianization” is a word that refers to the process of people changing from producers who make things, take care of people, and interact for use, to producers who produce for someone else, and only receive a wage in return. Someone who works for a wage is a “proletarian”.   It is another word for worker, and specifically for a worker who does not have control over their own time at work but instead is compelled to do whatever their boss tells them or else not make a wage.  Today, most of us are “proletarians”, but it was not always this way. Even those of us who work on contracts or work for ourselves are proletarians because the primary reason we are working is to make money to survive, not to fulfill ourselves and other humans.

The article discusses the process by which nurses went from being people who produced for themselves and their patients, to people who work for a wage for someone else.  It also shows that the development of hospitals, the exploitation of hospital workers, the division of labor by race and gender in the hospital, and the poor treatment of hospital patients are all rooted in the history of hospitals themselves.  This history is even more proof that any struggle for health and reproduction must be a workers’ struggle, and must seek overhaul the entire system since all abuses are intimately connected to the form of capitalist health care itself.  Despite the fact that Flo Jo believes we need to struggle to save closing hospitals, we also recognize the hospitals are often terrible places for both workers and patients.

As hospitals were organized more and more like factories, nurses organized like militant factory workers.

As hospitals were organized more and more like factories, nurses organized like militant factory workers.

The article is important because it shows that the capitalist mode of production, where workers produce not for use but so their work can be exchanged for money, is inseparable from the kind of care people receive.  It proves that there is no “ideal” that we can return to in hospital work; hospital work itself emerged as a way to both exploit workers (especially women) and to manage poor peoples bodies without giving much thought to how they would feel.  Although there is a lot of important information in the article, Flo Jo wants to emphasize a few main questions in order to relate the history of hospital nursing to the struggles in hospitals today against short staffing, internal fighting, and poor patient care.

How did Hospitals Come to Exist?

One very powerful aspect of David Wagner’s article is the description he gives of hospital nursing as a form of “primitive accumulation.”  Primitive accumulation is a term that refers to a period in history between the 1700’s and the 1900s when peasant farmers, artisans, and midwives (among others) were forced out of independent production for use and small scale exchange for goods and services, to produce for someone else, for a capitalist that could make a profit off the workers.  This was often a very violent process, where farms were destroyed, “witches” (many of whom were female midwives and healers) were burned, and people who refused to give up their independent production were imprisoned.  It was only through these means that capitalists, supported by state structures like the police and military, were able to force producers to become workers for someone else.

Despite the term “primitive” accumulation, we can see that primitive accumulation still happens today.   This is what happens when farmers in Latin America are forced to use genetically modified seeds instead of ones they cultivated, and it is what happens when people are prohibited from healing themselves using traditional means and are forced to use biomedical and capitalist medicine instead.   Primitive accumulation occurs anytime one way of doing things is abolished through law, violence, or changes in work processes (like automation), and when the goal of these changes is to pay workers less and lower the living conditions of all people.

Wagner lays out how this happened in nursing. Prior to the depression, most nurses performed a wide variety of tasks for a small number of patients.  Nurses had a wide knowledge of health and were in fact responsible for many medical advancements of the 19th and early 20th century, and would travel to the homes of 2-3 patients with whom they often had personable relationships; most of these patients were upper or middle class.  While Wagner does not describe how poor people and working class people were being cared for, other sources (like the famous Witches, Midwives, and Nurses) describe that the 19th century was a time when poverty became very material: as people were thrown out of production for use, they could not gain access to wage labor.  A whole new category of people was established, and many of these people were left without adequate ways to care for themselves.  In the 19th century, hospitals were developed to hold this new population of ill poor people created by the development of capitalism.  In addition to ill people, hospitals also became warehouses for any poor person who was left destitute by lack of work, family, or community.  Hospitals were initially not staffed by paid nurses, but by nursing students who worked grueling 12-16 hour days with no pay.  According to Wagner, because “each student nurse meant greater profit for the hospital, they were ‘trained’ at an incredible rate.”  In the 30 years immediately before the depression, the number of nursing students more than quadrupled.  The divide between people who had access to healthcare and those who did not was not fixed by the hospitals: instead the hospitals were part of managing the new classes of people struggling under capitalism, including the new classes of healthcare workers earning nothing in the hospitals.

By the late 1920s, 3/4 of nurses were private duty, but by the 1920s competition increased as more nurses flooded the labor pool encouraged by the unnecessary “training” of nurses to keep hospitals staffed with free labor.  Private registries developed which extracted fees and took over placement and hiring for private duty nurses (like home health aide, also known as HHA, agencies today). They hired and fired nurses at will, especially targeting rebellious nurses who refused to follow the increasing discipline of the registries.

During the depression, the incomes of middle and upper class patients who private duty nurses relied on dropped as millions were plunged into poverty.  The oversupply of nursing labor power and the increasing poverty of patients meant an increase in hospitals and a decrease in demand for private duty nurses.  In addition, many part-time, married, or retired nurses returned to the field to seek much needed income.

Much changed in nursing during this time.  One major change was the development of the American Nurses’ Association (ANA), the precursor to the New York State Nurses’ Association (NYSNA) and other state-level nurses’ unions.  The ANA developed as a nursing manager organization to manage the restructuring of the field.  While they certainly did much to save nursing, such as closing down inferior schools, they were never a fighting workers’ organization; their primary goal was to save the profession, not to fight for workers.  ANA even resisted wage increases and hour restrictions for nurses for several years because they did not want to threaten the field.  It is important to understand this history when we look at NYSNA and other antecedents of the ANA today and try to understand their history.  Later on, the ANA would take on a major role of stabilizing the often unstable hospitals often through new forms of worker discipline.

In the late 1930s and 1940s, Blue Cross/Blue Shield was introduced as the first major commercial health insurance.  Millions of people joined the rolls, which made hospital care accessible to many people.  The growth of the insurance roles showed that many people were living without access to healthcare; however, just being on insurance and having access to hospitals did not mean that people were able to receive quality care.  Essentially, just like the hospitals themselves, the growth of insurance was a way to avoid a rebellion of people who had no access to healthcare, while also engaging in the kind of accumulation we discussed before, creating the now lucrative insurance industry.

The increasing reliance on hospitals also meant the increasing exploitation of nursing staff.  As nurses still struggled to maintain their role as private nurses with a great deal of autonomy and time to spend with every patient into roles as part of a mass factory-like system of basic health care, resistance increased.  As the number of patients in hospitals increased, workers faced no sick leave, split shifts where nurses had to wait hours in hospitals to work one shift after another, low pay, and longer and more arduous shifts, workers began to rebel.  Management and many of the nursing associations responded by implementing “loyalty” policies, which required nurses to keep quiet about working conditions.  These loyalty policies are still carried out today under different names.  Today, pressure to not speak out about both labor and patient abuses for “the good of the patients” is enforced by both unions and management.

What is the relationship between the division of labor in hospitals and workers’ struggles?

As hospitals began to increase in size and number to accommodate the number new patients, and the growth needs of hospital owners, hospitals began to hire “subsidiary workers” such as Licensed Practical Nurses (LPNs) and nurses’ aids.  Hospitals did this to accomplish two goals: one, to create a constant threat to RNs positions both explicitly and implicitly as hospital management threatened that less trained workers making less money would take over Registered Nurses’ (RNs’) jobs.  This put pressure on RNs as well as LPNs to work harder for less money, and also caused severe splits between these workers who should have been in solidarity.  Two, it gave nurses supervisory power over LPNs; this further split the workforce, again pitting workers with a great deal of solidarity against one another as RNs took out their overwork and lack of pay on LPNs instead of on management.

The introduction of LPNs and other “less-skilled” workers like attendants, as well as highly specialized workers such as nutritionists, X-ray technicians, etc., was part of a broader attempt to divide workers and make hospitals more “efficient” to meet the growing need of an increasingly impoverished population of both patients and workers.

During WWII, another shift occurred.  The war required many health practitioners to go abroad, and created a shortage of nurses and other workers.  Wagner describes the shift this way:

The use of hospitals rose during World War II to its highest level. This growth in hospitalization resulted from a number of social and economic factors: the cut in the number of civilian doctors, limiting the possibility of office visits and home care; the absence of family members to care for patients at home; the rising rate of injuries, not only from the war but from industrial accidents; and the concurrent increase of Blue Cross/Blue Shield policy holders (particularly group hospitalization insurance secured by unions), which made hospitalization more available.

As hospitals became more profitable, and moved further away from the goal of caring for people and more towards efficiency, new models were introduced.  One was the “Lean” model, originally introduced by Frederick Taylor for auto production.  One of the most notoriously exploitative modes of working, Lean production requires time studies that show every second that can be cut out of work, and is usually accomplished by creating assembly-line workplace organization.  Anyone who has spent time in a hospital has seen this: patients are visited by several people of all levels of training and pay, and are forced to wait hours with very little human connection.  Lean production reduces costs but also reduces the level of care, and increases competition and separation between workers.  Wagner emphasizes that it was also in this period that hospital workers began to organize, many of them seeking out unions including unions traditionally for industrial workers such as the Congress of Industrial Organizations (CIO).

Wagner leaves us with these words about the role of professional organizations:

The professional leaders must hide this history–as they must hide the current similarities of nursing with other underpaid women workers–in order to retain control over their ranks. Hospital nursing, stripped of its prestige from close association with doctors and medical technology, bears strong similarities to factory work. The contradiction between this reality and professional nursing rhetoric is as constant a battle today as it was in the 1932-1946 period.

Mental Health: An example of proletarianization today

Many of the conditions in hospitals are similar today: workers fight one another more than the boss, the division of labor is more and more intense, and patients literally die while waiting for care that is “financially efficient” but insufficient for survival.  One of Flo Jo’s members works in mental health and sees similar structural changes in the care of mental illness, as those that took place in hospitals.  In particular, many mental health facilities operate with a disproportionately large number of managers to workers.  These managers act more like overseers of slaves on a plantation than bosses of workers in a health care facility. Because most of the activities workers do with clients do not necessarily help clients, both workers and clients have to be coerced by threat of punishment to carry out their tasks.  Just like the hospital management of the WWII era, these bosses-turned-overseers also use the division of labor and the idea of “loyalty” to quell resistance among both workers and clients. This has partially been accomplished by moving from large state institutions to smaller institutions.  Despite there being smaller institutions, the total number of workers has decreased, and the number of mental health patients has increased creating a dangerously high patient-worker ratio. Just like in hospitals, dangers that come from short-staffing are posed as problems with staff not “caring” enough and being “burnt out”.  Meanwhile clients are kept in institutions with the logic not that they need care, but that they are “too institutionalized” to function in the world around them. In this way, the healthcare industry has successfully created at least two generations of institutionalized people who are bereft of their own autonomy and caught in a matrix of being told “we need to care for you because you cannot care for yourself”.  Furthermore , the mental health care sector has created a booming industry around this population which increases possibilities to exploit case managers, social workers, HHAs, CNAs and other mental and disability health professionals.

What does this mean for workers and patients today?

There is a lot to be taken from Wagner’s article.  Most of all is the realization that we cannot simply defend the hospitals as the are, but that we need to transform healthcare as we know it, and the rest of the world around us.  The development of the hospital was predicated upon dividing workers by race, gender, education, and job description to make them more efficient and less cooperative, and to reduce patient care to its absolute minimum.  There is no ideal hospital that we can look back on to model our work.  Furthermore, as the final quote from Wagner suggests, the history of nursing is the history of the destruction of the livelihood of most of the world, built on the backs of women and people of color, to create the oppressive and sick hospital system.  The lives of nurses, their patients, and other workers–especially feminized and precarious workers such as retail, service, and home care–are intimately linked.  When we struggle, we have to struggle on the basis that our exploitation is tied up with one another.  We have to unite across job descriptions, communities, and workplaces.



  1. Vanessa Stephens Coldwater

    Wonderful article. I am an independent homebirth midwife and the issues raised apply to birth and midwifery care. The pressure to license, professionalize, standardize and institutionalize midwifery is enormous. Foor for thought, and helps keep the fire lit for maintaining and promoting autonomy and independence! The source material is well worth reading…. Thank you!

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