Essay
October 1999

Concrete vs. abstract labor in health care

by Htun Lin

The bourgeoisie cannot exist without constantly revolutionizing the instruments of production, and thereby the relations of production, and with them the whole relations of society...The bourgeoisie has stripped of its halo every occupation hitherto honored and looked up to with reverent awe. It has converted the physician, the lawyer, the priest, the poet, the man of science, into its paid wage laborers...because their specialized skill is rendered worthless by new methods of production...thus the proletariat is recruited from all classes of the population. -Karl Marx, COMMUNIST MANIFESTO

It may be hard to imagine doctors as proletarians. Yet how else can one construe the June 1999 call from the doctors of the American Medical Association (AMA) to unionize themselves? Doctors, who already have the highest wages and benefits, are proposing to unionize for the goal that animated the beginnings of unions in history: to gain control over their concrete labor.

This is no surprise to those of us who work at the giant Kaiser HMO where doctors have joined the fight against management's restructuring plans. The turning point at Kaiser, for service workers like myself, came in 1986 when we struck for eight weeks against introducing a two tier work force. Though it did not affect us personally, we fought for the principle of no second class workers. We also learned never to trust the labor bureaucracy which betrayed our struggle. (See "SEIU scuttles Kaiser strike," NEWS & LETTERS, Jan. 30, 1987.) What we've witnessed since is that access to affordable health care is an important dividing line, separating a growing second tier of the U.S. labor force.

Kaiser nurses of the autonomous California Nurses Association became much more radical after our strike. In 1995 they initiated a series of strikes against the erosion of adequate health care for Kaiser's predominantly poor and working class patient population. They won some specific powers over the quality of care they give. They also recently coalesced with a predominantly Black working class community in Richmond, successfully stopping Kaiser's medical red-lining plans.

Some doctors have joined the nurses in their demand for better health care delivery. They have come to realize the commodity nature of their labor under an increasingly corporatized and dehumanized health care system. There is a great divide between two worlds of health care-one with concrete human dimensions, the other abstracted to marketplace calculations. New layers of the health care work force are being forced to choose their side of this deepening divide.

Health care corporate giants like Columbia/HCA came on the American health care scene little more than a decade ago. Using their huge capital resources, they began to swallow up countless hospitals and nursing homes across the USA. The subsequent restriction in the quality and supply of healthcare was accompanied by the most ironic of popular labels: HMO, or Health Maintenance Organization, and "Managed Care." Many healthcare workers were saying the only thing "Mangled Care" managed was money, not health. That is precisely why health care workers from service workers to nurses and now doctors have been conducting a slow, simmering revolt against this increasing commodification of health care.

Health care workers across the country have been increasingly militant in their drive for "quality care," speaking out about their experiences and daily battles on the health care shop floor. Health care executives, increasingly uncomfortable with the light of day exposing the atrocities they have been committing against patients in the effort to enhance the corporate bottom line, have launched an Orwellian double-speak offensive. They have claimed that "less is more," that fewer available hospitals, hospital beds and staff actually promote "better quality." Other industry representatives have even claimed that "providing patients with more choices would lower quality." These same industry spokesmen are accusing doctors, nurses, and health care workers of a rhetorical offensive.

HEALTH EXECUTIVES' HYPOCRISY

Take one industry expert, Gerald Kominski, who claimed that the current AMA physicians' drive to unionize to bring back quality patient care "is just rhetoric...They're primarily concerned with protecting the profession's interests and income-the concern with patients is a convenient screen." This was the same smear tactic used against the nurses in the California Nurses' Association when they alone, without any help from the AFL-CIO (in fact the AFL-CIO colluded with company restructuring by entering into a "partnership"), successfully fought to bring the first ever "quality care" provisions into their current contract with Kaiser Permanente.

Dr. David Lawrence, Chairman and CEO of Kaiser Permanente, delivered an astonishing speech in July 1999 to the National Press Club. He declared that "medical accidents and mistakes kill 400,000 people a year, ranking behind only heart disease and cancer as the leading cause of death." "Mistakes alone," he said, "kill more people each year than tobacco, alcohol, firearms or automobiles." Even more astonishing, Chairman Lawrence said, "If passengers were asked to fly with a commercial airline organized like most health care, they wouldn't get on the plane."

As head of the nation's premier and first HMO organization, Lawrence's words had the ring of a spontaneous confession. One would have thought that, in this rare moment of honesty by an industry executive, he would have perhaps weighed in heavily on the current debate in Congress over the "Patients' Bill of Rights" by siding with the patients, health care professionals and workers of America. Instead, in a stunning move full of macabre irony, Lawrence chose to lay blame for these medical atrocities on the nurses, doctors, and other health care professionals, rather than placing the responsibility squarely on the HMO industry itself.

Lawrence then boldly declared that he and some health industry leaders have "organized foundations and commissions aimed at aggressively tackling the problem of patient safety." He said he wants "improved reporting about medical mistakes and gathering of information about near misses." However, it was Lawrence himself who insisted on a gag rule in the implementation of quality provisions negotiated by Kaiser nurses. Against the nurses' insistence, he wants no public airing of medical mistakes discovered by the nurses' quality liaisons.

Kaiser management's determination to hide real life data on health care shows that it is THEIR talk of "patient rights" which is empty rhetoric. The latest contract settlement with the Kaiser nurses over the issue of quality care was signed in March 1998. However, its "quality care" provisions have yet to be fully implemented. Throughout the 18 month strike period, Lawrence fought tooth and nail against his own nurses at Kaiser, and had vowed, at one point, to "never give in" to the nurses over the issues of control over quality.

The battle lines over the attitude towards health care has never been more concrete-and universal. No longer can anyone afford to not take a side. Not legislators. Not judges. Not even doctors. The nurses and service workers have always known which side they were on in the battle over the commodification of health care, in which health care restructured into "managed care" concentrated more and more capital in the hands of fewer and fewer HMO money managers. Their mission was "delivering" health care according to the dictates of the "market," which means maximizing profits, not patient well being. Many advocates have exposed the very real atrocities suffered by patients under the steam roller of "managed care."

The drive to cut costs shows how little a capitalist society values the health of workers-especially the poor and unemployed worker. The only resolution, and hardly anyone looks there, is through workers, in this case health care workers, having control over their own activity and its meaning.

THE REASON OF THE HEALTH CARE WORKER

It is in the activity of the health care workers where the locus of the battle over the control of quality care vs. its commodification resides. Health care corporate executives know very well, as does the front line health worker, the very real daily struggle over the staffing levels, speedups, de-skilling, and downsizing of health care laborers in the face of ever increasing demand for health care labor by an expanding and older patient population. Much of that reality has been discussed with euphemistic (and misleading) rhetoric couched in terms of "available hospital beds," "scarcity" of "health care dollars" and "runaway health costs."

Those who control the reins of our health care dollars-the HMO executives-openly pose the health care crisis as an either/or choice. Either we solve the "crisis in health care cost" or we address the "crisis in patient care" by expanding patient rights. HMO executives claim that the "Patients' Bill of Rights" backed by health professionals would make health care less affordable and accessible by "unnecessarily" mandating certain care standards, thereby bringing up the cost of health care. In other words, we would necessarily have to be killing Peter to save Paul.

Such sophistry only focuses on the surface, the realm where commodity fetishism and the bottom line rule, where the exchange between things and interaction between dollar figures dictate interpersonal relations between human beings. Such sophists have not allowed us to look into the nature of the commodity itself, by delving into the meaning of our activity through human relations in our workplace.

The one unifying concept which is now animating all levels of health care workers is opposition to speedup. The notion which motivates and animates the health workers', the nurses', and now, the doctors' drive to take the lead in self-activating their status as union members, is the general notion of regaining control of one's own work activity on the shop floor. This is couched, for the physicians, in terms of "regaining control of the doctor-patient relationship"; and for nurses, in terms of "nurse-to-patient ratios." The latest episode of that struggle came not only in the form of AMA doctors wanting to form a union, but also in the increasing number of rank-and-file Kaiser doctors who signed on to a petition refusing to cooperate with an impending Kaiser merger with Summit, which, in turn, is positioned to be swallowed by health giant chain Sutter.

I remember when AFL-CIO President Sweeney gave a very fiery speech in front of Kaiser Hospital in 1995. It was at the height of SEIU's corporate campaign against managed care in which he proclaimed: "Patients are not parts on an assembly line, and patients should not be treated as commodities." (This was before his betrayal of the nurses in the midst of their strikes with an announcement of a new "strategic partnership.") Many of us who were present at that rally wondered amongst ourselves, "then why is my labor a commodity?" Why is my labor being bought and sold, like any other commodity, and our labor leaders bargain with the employer across the bargaining table the price at which my labor will be sold?

HMO executives fight at all costs the emerging resistance of health care workers-a resistance coming from active questioning of the meaning of their own labor. This kind of "collusion" by health care workers, this kind of solidarity, unity in thought and action, threatens the very core of the existence of the commodity fetish in health care. They see correctly that, once workers gain control of the very specific activity of their own work, the very fundamental commodity nature of their labor begins to unravel. Speedups and de-skilling would be difficult under such circumstances. Without the implementation of further speedups, de-skilling, and other controls over the quality and pace of production, the managers of capital would find it very difficult to maintain the rate of increase in surplus labor they can extract in order to maintain the desired rate of profit, in order to be "competitive" in the marketplace.

Managers carry on endlessly about the need for "teamwork" and "cooperation" which is praised to the heavens as long as it increases efficiency and the bottom line. Their concept of cooperation is always under the rubric of cutting cost and labor time. In society as a whole the attack on health care cost is aimed at bringing down the cost of labor, which in capitalist terms is merely human "capital." Because under capitalism labor is the commodity of commodities, health care holds a unique position in the extraction of surplus value. Any attempt to fully take control of the basis of our cooperation is called "socialism." At the same time, that doesn't keep capitalist managers from trying to take credit for positive socially cooperative endeavors.

The present stage of permanent restructuring is revealing that there is no longer any middle ground or compromise with the logic of restructuring. You either take the side of capital, HMO executives, and the labor bureaucracy or the side of doctors, nurses and other workers fighting over the meaning of their concrete human labor. In order to create our humanity, basic human cooperation and free association has to determine our priorities. Health care is a service centered on the well being of the human being. De-masking the production process in health care can lead to demasking it in all areas of life. An unraveling of the present mind-forged view of the production process would spell the disintegration of the neatly ordered process of commodity production's extraction of surplus labor in health care to generate profits.

It is high time to stop allowing the dictates of capital in any form to determine the nature and direction of our fundamental drive towards freely associated social cooperation. Not only that, we must stop seeing through the distorting prism of capital to construct social labor and social production. We need autonomous unions-like the CNA. However, only full social cooperation that cuts across all professional boundaries and classifications can lift the false sense of reality that animates capitalism in which we all participate. The nurses did show that autonomy was a way not to get caught in that other backward thinking layer outside of production-the labor bureaucracy. In addition to autonomy, the full potential of our movement will not be reached until we face this reality through a philosophy that brooks no compromise with the anti-human logic of capitalist restructuring. Therein lies the relevance of Marx for today.

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