Vocational exploitation (1985)

From the May 1985 issue of the Socialist Standard

Nurses often cherish an illusion of "professionalism" despite the fact that they are subordinate to medical staff, are poorly paid, work shifts, weekends and public holidays (for which they receive lower rates of enhanced pay than most other workers), have poor working conditions in the majority of cases, and engage in stressful, demanding work within the rigid discipline of a status-conscious, hierarchical organisation.

Nursing qualifications are protected by law and it is a punishable offence to make a false claim to be a trained nurse. But there are two levels of qualified nurses. Registered nurses have qualifications which enable them to aspire to higher positions while enrolled nurses are unable to gain promotion beyond senior enrolled nurse grade. Doyal has pointed out that overseas nurses coming to Britain to train are encouraged to qualify as enrolled nurses only to find that their qualifications are not recognised in their own countries. She states:

  Nurses born overseas are over-represented in hospitals dealing with mental illness, mental handicap and geriatrics, and very few indeed are to be found in the "prestige" teaching hospitals. Overseas nurses are, therefore, clearly used to compensate for the shortage of British recruits into notoriously underpaid and often unpleasant work. Their role as a “reserve army" has recently been demonstrated with particular clarity by the fact that because of high levels of unemployment among British nurses, overseas nurses are increasingly being refused a renewal of their work permits.

Nursing auxiliaries, although forming a substantial part of the work force, are untrained and unable to call themselves nurses.

The nurses' professional organisation, the Royal College of Nursing, tends to be dominated by senior nurses and excludes nursing auxiliaries from membership. Indeed, prior to 1960 male nurses and enrolled nurses were also excluded. The RCN, in an attempt to maintain professional exclusiveness, has asked for nursing auxiliaries to be omitted from pay negotiations. The conservatism, elitism, avowal not to strike under any circumstances and tendency to concentrate on pay campaigns in favour of nursing administrators, have helped successive governments to divide the workforce and made their task of keeping wages low that much easier. Although in recent years the RCN has adopted a slightly more radical stance (possibly to avoid losing members to the trade unions representing nurses — NUPE. COHSE and NALGO) it remains a reactionary, divisive force.

A profession can be defined as an occupation requiring advanced education and nursing can reasonably be considered as such. However, the subordinate role of nursing has been demonstrated by the case of Derek Owen, a former staff nurse at Walsgrave Hospital. Coventry, who refused to participate in administering electroconvulsive treatment to a 76 year-old woman and was sacked. At the employment tribunal hearing Justice Popple well stated: “. . . it's not the nurse who decides what treatment a patient would benefit from, but the doctor" (Nursing Times, 1984). Iliffe deals bluntly with the much vaunted professionalism in nursing:

  When nursing is restricted to mopping-up vomit, emptying bedpans and washing the bed-bound, it is only a special example of the caring role allotted to women, and nurses are therefore allotted the same autonomy as women generally. Nursing "professionalism", therefore, aims at acquiring trade secrets (more politely called professional skills and knowledge) to give some nurses more autonomy, status and money. The evolution of special skills and knowledge necessitates a special education, with access to it restricted to ensure that the market is not overloaded with tradesmen.

The appeal to professionalism is also used as an unsubtle form of blackmail to coerce nurses into docile conformism. The fact that trained nurses risk losing their qualifications through taking effective industrial action assists considerably in maintaining a compliant labour force.

When carrying out dirty work some form of protective clothing needs to be worn, but nurses insist on calling their overalls "uniforms" and wear useless frilly hats, perpetuating their domestic servant/hand maiden image. When their uniforms were compared with ". . . a plumber who insists on wearing a puce boiler suit, a purple beret, and his City and Guilds Certificate pinned to his chest!" (Pinel) there were horrified letters of protest in the nursing press. It is easy to dismiss the different coloured "uniforms" as a harmless, outdated tradition, but its perpetuation is designed to reinforce the rigid hierarchical structure and promote status consciousness. Servile, unquestioning workers accustomed to knowing their place within the organisation, dressed in a "uniform" designed for Victorian domestic servants, are easier to control.

Unlike other shift workers, nurses talk of their "duties"—a euphemism which disguises public holiday, weekend and night work often far in excess of shift workers in factories. It is only in the last twenty years that nurses have been able to receive extra pay for working unsocial hours and even now, in spite of being gradually increased over the years, nurses receive only time and one-third for Saturday, "unsocial hours' and night work and time and two-thirds for Sunday and public holiday work. These rates lag well behind those paid in industry or. indeed, the rates paid to hospital ancillary staff.

With 10.000 nurses and midwives without jobs, a large pool of unemployed labour to fill nursing auxiliary vacancies, reduced demand for labour as hospitals are closed as a result of cutting resources to the health service and the weakness of trade unions during a recession have emboldened the government to try to abolish enhanced rates of pay for unsocial hours. Such a move, if successful, would cut the nurses' standard of living and reverse twenty years of struggle to achieve pay conditions comparable with industrial workers.

Many hospitals were built in the Victorian era and are still in use today. Poor Law infirmaries, former workhouses and prison-like asylums still serve as district general hospitals, geriatric hospitals and psychiatric hospitals. With the cut-back in health service expenditure those hospitals that have survived closure have been patched up in a haphazard and piecemeal manner. The old buildings were never intended for modern nursing and condemn nurses and patients alike to substandard conditions. Very few buildings have been constructed to replace old hospitals. In the first seventeen years of the National Health Service only one new hospital was built. But as Widgery points out;

  . . . the size and location of the finished new hospitals often worsens rather than improves the national distribution of medical resources. The Royal Free in Hampstead is situated in the most affluent and healthy part of North London, while hospital facilities in the Northwest London industrial belt and in East London are being closed.

Such closures oblige nurses to move or travel long distances to work.

Residential accommodation for nurses has been the subject of several campaigns to secure improvements. However, the government intends to sell off two thirds of the nurses' homes (presumably that which is most profitable to speculators) and retain only a minimum stock of housing. Nurses, at the mercy of private landlords, would find their living standards declining further:

  Resident nurses are frequently subjected to a number of petty restrictions which would not be tolerated by private tenants elsewhere, and must represent one of the most pernicious forms of "tied cottage" arrangements in existence today (Pinel).

The lodging charges for resident nurses were due to increase by 5 per cent from 1 April 1985 although the government has announced that nurses' wages must not rise by more than 3 per cent.

Nurse managers have opted out of nursing practice to "police" other nurses. They accept extra remuneration (or bribes) to enforce discipline, increase exploitation and punish their fellow workers, although as workers themselves they are dependent on the posts they hold for their livelihood. Male nurses, although making up less than 10 per cent of the nursing labour force, occupy one-third of the senior administrative posts, reflecting the sexist divisions of the broader society while the dearth of immigrants in senior posts is part of a deliberate policy for, as a Lanarkshire Health Board Memorandum stated: "No alien (Mauritian. Filipino. Chinese) person is to be promoted without the sanction of the Home Office" (Nursing Mirror, 1980).

During an industrial recession there is a surplus of labour and it is not so profitable to spend money conserving the workers' health. Cuts in the health services and hospital closures have, therefore, weakened the bargaining power of nurses. But the divisive "professional" stance of nurses, their failure to recognise their class interests and to understand the exploitative role of capitalism have depressed the conditions of Britain's 350.000 nurses and assisted successive governments in under-funding the health service.

Carl Pinel

References

Doyal, L. with Pennell. I. The Political Economy of Health. Pluto Press. 1979. p.206.

Iliffe. S. The NHS: a Picture of Health? Lawrence and Wishart, 1983. p. 147. 

Nursing Mirror. News item. 151 (20) 4. 

Nursing Times. News item. 80 (43) 5.

Pinel. C. "Are uniforms necessary?" Nursing Mirror. 14 November 1974, p.41.

Pinel. C. "'Us' and 'them' at work". Nursing Mirror. 158 (10) 9.

Widgery. D. Health in Danger. Macmillan Press. 1979. pp. 52-53.

Commerce and Cancer (1986)

Book Review from the February 1986 issue of the Socialist Standard

Cancer in Britain: the politics of prevention. Lesley Doyal (Editor). Pluto Press. £5.95.

This book is a sequel to Epstein's influential The Politics of Cancer and examines the dangers to health of carcinogens in industry, food additives, tobacco, environmental pollution, drugs such as female sex hormones and oral and injectable contraceptives in Britain.

Cancer is regarded by the authors as a preventable disease and they are critical of the curative emphasis that dominates most research, pointing out that the rates of cure for most major cancers have improved only slightly in the last 30 years. There are marked differences in the cancer rates of urban and rural areas, with very high rates of lung and stomach cancer in the industrialised inner-city areas — a pattern previously observed in the United States. The major cancers are common among semi-skilled and unskilled workers, particularly men, probably reflecting in part their greater exposure to occupational carcinogens.

The authors explain that there are two distinct approaches to cancer causation — the "establishment" approach which argues that occupational cancers cause less than 5 per cent of all cancers and resists attempts at regulation of industry, claiming that people's "life-styles" are responsible; and the "radical" approach which argues that 20-40 per cent of cancers are work-related and aims at better health and safety measures at work.

A comprehensive account is provided of the dangers of working with carcinogens; how industry resists attempts to make working conditions safer and how comparatively few people are able to obtain compensation once they have developed cancer through their work. The difficulty of regulating industry is increased by the manufacturers' secrecy, although as ASTMS have pointed out:

The chemical companies have no secrets from one another: each can analyse the product of its rivals within hours in an analytical laboratory. The real object of "commercial secrecy" is to keep information out of the hands of the unions, (page 38)

The pursuit of profit, not lack of knowledge, lies behind the failure to make the working environment safer. There are, for example, about 2.000 asbestos-induced deaths each year and although a Home Office report pointed out the dangers as long ago as 1906, regulations to control the levels of asbestos dust were not introduced until 1932.

The most flagrant examples of commercial interests influencing the regulation of dangerous substances can be seen in the case of the pesticides aldrin and dieldrin, which are banned in the United States but used and manufactured exclusively in Britain, and chlordane and heptachlor which are restricted in Britain but made and used in the United States. The failure of successive governments to regulate the tobacco industry and prevent the 50,000 deaths a year caused, at least in part, by smoking is influenced by the £4,000 million received every year from tobacco tax. The book points out that “. . . the financially precarious newspaper industry earns more than £30 million each year from advertising, a fact reflected in the consistent refusal of newspapers to criticise the industry or to support campaigns for stricter regulation" (page 81).

Perhaps the most tragic aspect of the use of carcinogens has been in the treatment of pregnant women with diethylstilboestrol, mainly in the 1950s. The drug actually increased miscarriages and baby deaths instead of preventing them, caused abnormalities in the offspring and an increase in the incidence of breast cancer.

In a chapter devoted to fighting the causes of cancer it is stated that "The problem is inherent in the nature and priorities of a society in which the profit motive is predominant" (page 147). Reformist measures such as campaigning for a Freedom of Information Act and more public participation in decisions are advocated and are doomed to failure under capitalism because of their effects on profitability. Socialism is not mentioned.

Nevertheless, despite its faults, this book is well researched, well referenced and provides a lot of useful information about how one-fifth of us will die prematurely to provide profits for capitalism.

Carl Pinel

Health vs Profit (1983)

Book Review from the October 1983 issue of the Socialist Standard

The Political Economy of Health (Lesley Doyal with Imogen Pennell), Pluto Press, 1979 (h/b £10, p/b £4.95)

This interesting and well referenced book provides an analysis of health in Britain, public health, medicine and the development of British capitalism; the role of capitalism in determining health patterns in underdeveloped countries and the effects of colonialism on the health of indigenous populations; sexism within the National Health Service. The basic assumptions that health and illness are predominantly biologically determined, that medicine is a value free science and that scientific medicine provides the only viable means for mediating between people and disease are all questioned.

The conflicts between health needs and capitalist pursuit of profit are well illustrated: where improvements have occurred it is usually because of political expediency or because it is profitable to do so. The public health reforms initiated by the 1848 Public Health Act which reduced deaths from cholera by improving sanitary facilities were motivated by fear of the spread of epidemics to the rich, the escalating cost of poor relief to families made destitute by disease and the risk of Chartist agitation against the wretched conditions endured by the working class.

There are statements that socialists disagree with: " . . . we can assume that under socialism profit would no longer be the criterion for making decisions about production or consumption. Very different goods could then be manufactured. possibly using alternative technologies, with labour organised in less damaging ways, and income more equally distributed”. Although the first part of the statement is sound there will be no money in a socialist society and, therefore, no income to distribute.

The 'Inverse Care Law’ described by Julian Tudor Hart is incompletely quoted on page 197. "In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case loads with less staff and equipment, most obsolete buildings, and suffer recurrent crises in the availability of beds and replacement of staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served". The omitted crucial final sentence is "This operates more completely where medical care is most exposed to market forces and less so where it is reduced”.

The book shows how colonial exploitation caused malnutrition by enforced changes in traditional methods of agriculture, exacerbated by the cultivation of “cash crops" such as tobacco or coffee. Diseases such as yellow fever, leprosy, hookworm and yaws were carried from West Africa to the Americas as a result of the slave trade.

The exploitation of women as health consumers and employees is argued. However, one feels that the authors are on less certain ground when they state: "It is difficult to articulate the medical model of women in any systematic way. It is not spelled out in textbooks, and must be constructed from an examination of the nature and content of medical education and medical practice”.

The influence of medical staff in the status-oriented and sexist National Health Service is examined with its emphasis on high technology and curative medicine at the expense of resources allocated to long-stay hospitals and preventive medicine. Private medical schemes are organised by employers as incentives and rewards for managerial staff during periods of wage restraint. As the authors state: “the continued existence of private practice makes it possible for overall standards in the NHS to be reduced without affecting the health care of the decision makers themselves".

Although socialists will find points of disagreement in this book the authors have produced a readable, well researched book rich in valuable reference material. The Political Economy of Health should be read by all socialists engaged in health care and may well become a standard reference work by which future books on health care are judged.

Carl Pinel