Tonia Bazel didn’t want to strike during a pandemic, taking time away from the patients on the infectious disease floor where she works. Nevertheless, she and the other nurses at Albany Medical Center in New York took to the picket line on December 1. They had been bargaining for two years following their vote to join the New York State Nurses Association (NYSNA) in 2018, and although wages and benefits had been the source of their initial concerns, conditions during the Covid-19 crisis had become the focus of their action. As a second wave of the virus began to wash over the state, they went on strike to demand better protective equipment and safer staffing levels.
“Staff have been leaving,” Bazel explained, adding that their departures have only exacerbated the conditions that prompted them to leave. “The hardship at the bedside has become more stressful for those who are staying. More of us are getting sick.”
Of particular concern has been the continued rationing of personal protective equipment. Months into the pandemic, Bazel said, “the mask I’m wearing, the surgical mask, I can find in Walmart all day long. So I’m trying to figure out why I’m rationed to one for a 12-hour shift among Covid patients.”
In her 24 years as a nurse, Bazel said, she’s gotten used to the fact that nurses are rarely asked what they need to do their jobs well, whether it’s more PPE or improved staffing levels. She’s used to being treated as though she’s replaceable, as though the institutions would rather push out experienced nurses like her and hire newer, cheaper staff instead. But as the caseloads crept up and she went to work day after day in a reused mask she considered unsafe, as more of her colleagues were out sick with Covid-19, and as the hospital refused to budge on nurses’ demands for improved conditions—even though those conditions would offer better patient care—it became too much. She and her colleagues decided to strike.
“Every time I walk in, I’m at risk of bringing something home,” she explained. “Everybody fears that, but administration doesn’t. They never have to enter the floor.”
Bazel is one of millions of health care workers doing their best to save lives despite conditions that are difficult at the best of times. Nurses like her have long been the difference between life and death for scores of people, yet their work has often been undervalued and their expertise dismissed. Now, it is nurses like her who are leading the outcry against the inadequacies of the American health care system, challenging us to think about the ways our crumbling patchwork of private institutions propped up by public funds has left us vulnerable to the virus.
The Albany nurses struck for one day as planned, carrying signs that declared, “All I want for X-mas is PPE!!!” and “Protect Nurses and Patients!” At the end of 24 hours, the hospital refused to let them return for two additional days. In a press release, it defended its record: “Safety is Albany Med’s top priority. The Medical Center follows all federal and state PPE guidance and maintains an adequate supply of PPE.” Nonetheless, the nurses have continued to organize, meeting regularly while awaiting the results of several Occupational Safety and Health Administration complaints.
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Nor have they been the only ones to resort to protest and work stoppages to make their demands felt: Nurses at Montefiore New Rochelle Hospital in New York and St. Mary Medical Center in Pennsylvania, as well as a four-hospital-wide group of nurses in California, are just some of those who have gone on strike in recent months. Around the country, nurses are demanding that we go beyond the platitudes about “health care heroes” and commit to building a real national health care system, so that they are never forced to work in conditions like these again.
Julie Keefe is a nurse at Kingsbrook Jewish Medical Center in Brooklyn, and like Bazel and many other nurses, her frustrations with rationed protective equipment, short staffing, and the endless pressure to do more with less have brought her to the realization that the health care system needs radical change. For her, the months of March through May last year were a period of extended stress. “There was a general feeling of anxiety throughout the hospital,” she said. At that point in the crisis, the entire hospital was basically filled with Covid-19 patients, and the lack of equipment was getting to the staff.
Keefe has worked in respiratory care at Kingsbrook since her graduation from nursing school in 2012. Like many nurses, she said, she went into the field to help people. “It is a cliché, probably, but it’s true.” After taking some time off to have a child and be a full-time parent, she returned to the hospital because of the crisis last year. Although the work had never been without its challenges, she was surprised to find a drastically different place than she remembered.
In the earliest, most brutal days of the pandemic, when Keefe and her coworkers arrived, they would each suit up in their one gown and N95 mask for the day. When they needed a break, they would remove that one dirty gown and mask and then carefully put them back on to perform procedures that, Keefe noted, generate a lot of aerosols—the droplets that spread the virus. They planned carefully when they visited patients’ rooms, trying to anticipate needs so they could make as few trips as possible. At any moment a “code” might be called: the alert that a patient was in need of resuscitation. Those alarms were heard “much, much more frequently” than in the past.
“For so long in our hospital, we’ve been dealing with understaffing and lack of resources and supplies, but now all those conditions are exacerbated,” Keefe said. “It is even harder to provide the type of care that you yourself would consider to be good or adequate. You’re working hard, you’re trying your best, you’re anxious and tired and overstretched, and you also feel that you’re not doing a good job, you’re not doing right by your patients. It can be crushing.”
To understand how nurses like Bazel and Keefe came to be at the forefront of the fight to save both lives and health care itself, it helps to retrace the evolution of nursing, to understand the forces that have shaped it and the forces against which nurses have long been pushing.
The American health care system has relied on such dedicated women to keep it afloat from the start. That’s because hospital nursing has been shaped indelibly by the notion that it is women’s work. While men have gradually filtered into the field (in 2019, nearly 11 percent of registered nurses were male, up from 2.7 percent in 1970), gendered expectations continue to define the profession. And as I argue in my new book, Work Won’t Love You Back, such expectations have increasingly served, as industrial work waned and service work expanded in its place, to pressure more and more of us to work for love, not money.
Modern nursing has its origins in the home, where women were presumed to do the caretaking, as well as the cooking, cleaning, and child-rearing, all out of love. When more and more women began to work outside the home, it followed that they must be doing so for selfless reasons there as well, rather than because they needed or wanted to be paid. “To the doctor,” wrote Barbara Ehrenreich and Deirdre English in Witches, Midwives & Nurses: A History of Women Healers, the nurse “brought the wifely virtue of absolute obedience. To the patient, she brought the selfless devotion of a mother.”
Florence Nightingale, the British reformer who launched modern nursing when she opened the first secular nursing school in 1860, argued that such training would bring a more genteel class of women to the work than those who might do it merely for money. American reformers likewise emphasized the nurse’s caring mission in order to “reconcile commitment to paid work with cultural expectations for womanly service,” according to Barbara Melosh in “The Physician’s Hand”: Work Culture and Conflict in American Nursing. Women could work, in other words, so long as they didn’t expect the same treatment—or wages—as male workers.
Despite this image of nursing as an extension of women’s supposedly innate propensity to care, it “is really difficult cognitive work,” said Suzanne Gordon, author of several books on nursing and health care. “It’s brain work, not heart work.” Yet, she noted, ever since Nightingale moved nursing into the hospital, doctors and administrators have objected to the idea that nurses are knowledgeable. Nurses have had to struggle to be taken seriously as workers, to have all the parts of their job acknowledged as skilled labor.
That struggle has continued into the present, said sociologist Lisa Huebner, author of Catheters, Slurs, and Pickup Lines: Professional Intimacy in Hospital Nursing. To this day, hospital administrators assume that nurses are “naturally caring” rather than skilled workers who have learned what it takes to soothe and cajole the same way they learned to give an injection or administer a nebulizer. The presumption that their work is “a gift, a calling, or a sacrifice” makes many of the skills of nursing invisible. For instance, administrators classify time spent with patients as “nonproductive time,” even though it not only helps the nurses do important diagnostic work but also provides the intangible good feeling that hospitals count on to stay in business.
The expectation that good nurses are self-sacrificing is especially dangerous in the current pandemic, Huebner said. “If all we have to draw on is this dominant sacrifice narrative, this selfless image of this woman who is just doing everything she can to care for her patients, then we are not going to make important what it is actually going to take to do that work, including protective gear.”
If we assume, that is, that nursing is soft work that just requires having some caring feelings, we miss out on the danger that nurses face when they go to work underequipped. If we expect them to be self-sacrificing, we shrug off their deaths as inevitable sacrifices rather than failures of preparation—failures that come from management and from the state.
Management and the state—or, more precisely, capital and the state: These are the other forces that have long shaped the nursing profession, molding it to fit the market-based hospital system that developed alongside industrial production.
Health care, Melosh wrote, is “a rationalizing service industry,” driven by the cult of maximum efficiency. As it moved into the hospital in the early 20th century, the hospital came to resemble the factory, with efficiency experts and scientific management consultants looking to wring the last dollar from the workers. It was much the same as in any automobile factory, albeit in hospitals, the workers’ supposedly altruistic motivation became the excuse to keep wages low.
Yet hospitals are not factories and patients are not widgets. Illnesses, as the coronavirus is reminding us again and again, are idiosyncratic things, requiring constant innovation and a human touch. And the nurses who have often provided that touch have proved adept not only at providing care but also at agitating for better care—both for themselves and for their patients.
While doctors have tended to resist any threats to their autonomy, nursing quickly became a collective practice, and such collectivity lent itself to organizing. As early as the 1930s, nurses began demanding improvements like staffing ratios, which limit the number of patients a single nurse must care for. And by the mid- to late 1940s, as a nursing shortage gave nurses more power on the job, professional nursing associations began stepping up their activity.
During this period, some rank-and-file nurses turned to unionization, even as most nurses were denied collective bargaining rights; private nonprofit hospitals, which represent the majority of hospitals in this country, were exempted from labor law from 1947 until 1974. Nevertheless, the 1960s saw a wave of nurse organizing. It arrived during the growth in public-sector unions and the expansion of the health care industry—an expansion made possible not only by the creation of Medicare and Medicaid in 1965 (which poured more public money into the system) but also by the health care benefits won by those growing unions. Nurses took action both inside and outside of collective bargaining, and it was their agitation that led to their eventual inclusion in the law.
Part of what defined these early efforts was that, when nurses did try to organize, they tended to focus on changes such as staffing ratios rather than or alongside bread-and-butter concerns like pay—a tendency, Melosh noted, that many labor organizers did not understand. Decades later, this practice would be recognized as a form of “bargaining for the common good,” a strategy in which unions, working with community groups and those they serve, bring demands to the bargaining table that benefit the broader public. As far back as the late 1960s, New York City nurses (along with other heavily unionized hospital workers) fought for staffing, funding, and eventually, during the fiscal crisis, the hospitals themselves, said historian Joshua Freeman, author of Working-Class New York. New York’s public hospital system had been a jewel of the city’s welfare state, and its union workers fought for their own interests, yes, but also for the survival of the institutions—a battle that was only partly successful.
More recently, beginning in 2012, nurses in New York City mobilized alongside community groups to save two Brooklyn hospitals, Interfaith Medical Center and Long Island College Hospital. It was Julie Keefe’s first year on the job and also the year that a reform slate took power within NYSNA, pledging to fight for patient care. The nurses, including Keefe, held rallies, protests, and a “race for care” to dramatize the distance patients would have to travel if Long Island College Hospital closed. Their efforts yielded at least a partial victory: One hospital was spared.
“At Interfaith, they won that battle,” Keefe noted. “They stayed open.”
In the decades between New York City’s fiscal crisis and the protests in which Keefe fought to save two Brooklyn hospitals, the political economy of the United States shifted dramatically. Industrial labor declined and the service economy exploded—and with it, hospitals grew as well. Indeed, as Gabriel Winant writes in his forthcoming book, The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America, women were drawn into the labor force to make up for men’s lost income, and many of the jobs they found were in health care.
But while the health care system expanded, its growth hasn’t translated into fairer pay, better staffing ratios, or better health outcomes. Instead, while health care programs, according to Winant, “have emerged as by far the most significant stream of public social expenditure,” that money flows into private coffers, as private providers have expanded to keep up.
The problems with this setup have been obvious since early on. Between public programs like Medicare and Medicaid and employer-provided insurance, there was money to be made in the health care field—if you owned the means of care, that is. As that led to ballooning public spending, policy-makers changed the billing models in an attempt to cut costs—a development that led to the rise of managed care.
“Health care workers ever since have been caught between the shearing forces of constantly growing demand—since our institutions still route so much of our social welfare spending through the health care system—and politically imposed constraints on budgets, which health care administrators pass on to workers in the form of wage suppression and understaffing,” Winant explained. “This is how the ‘essential worker’ was invented, the figure who is indispensable yet disposable.”
Toward those cost-cutting ends, the industry adopted a policy of “lean health care,” modeled on the auto industry’s concept of lean production. Over the 1990s and 2000s, that meant pressure to do more with less and the same sort of just-in-time production and distribution that sees any sort of redundancy as wasteful, “whether that means stockpiles, whether that means unused beds or reserve facilities that can quickly be reactivated,” Freeman said.
It has also meant more nursing shortages, as conditions have worsened, along with a heavy reliance on immigrant labor: Some 17 percent of health care workers in the country are immigrants, and they tend to be concentrated, Huebner noted, in the spaces in the industry with fewer resources—and likely fewer protections.
All of this set the stage for the disaster that met nurses when Covid-19 struck: the lack of preparedness, the missing protective equipment, and the pervasive understaffing. And all remain enduring problems, the results of a system where the lines between “public” and “private” are constantly blurred, where the drive to maximize revenue exists in tension with the need to produce good health outcomes, and where workers like Keefe and Bazel are caught in the middle.
Within this system, the rise of militant, politically progressive nurses’ unions has been a beacon of clarity. The California Nurses Association (CNA) won legal staffing ratios in the state in 1999 and led the process of creating National Nurses United (NNU), merging with United American Nurses and the Massachusetts Nurses Association in 2009. The union now represents some 150,000 nurses nationwide and is a leader in the fight for single-payer health care, or Medicare for All. Unaffiliated unions have also grown more active—since 2012, NYSNA, Keefe’s and Bazel’s union, has changed greatly, playing a key role in the recovery efforts after Hurricane Sandy devastated New York City’s outer boroughs. These nurses’ unions, Freeman said, are “very militant, not intimidated by the expertise of anybody else, [and] often tied to broader left-wing social movements.”
For many years, nurses’ associations were dominated by nurse supervisors and academics, more concerned with professional prestige than shop floor action, explained Mark Brenner of the University of Oregon’s Labor Education and Research Center. But the arrival of lean health care, he said, pushed many nurses to consider a more militant unionism. The success of CNA in California didn’t hurt either, as nurses looked around for solutions to the crunch they were facing. The staffing problem, Brenner added, was a way in for nurse activists to begin talking about the problems of corporate health care, and it led to the kind of activism that NNU is known for on the national level.
But for most nurse unionists, their first motivation remains improving conditions at the patient’s bedside, and it is those conditions that have led nurses like Bazel to strike.
Deciding to walk off the job is a hard choice for most workers; when one’s work is producing not car parts but healthy patients, the decision is even harder. Nurses’ strikes can be frowned on by the public—unless, that is, the nurses do the work of organizing the community to support them. In this context, the work that unions like NYSNA have done (providing emergency care after Hurricane Sandy, battling to save beloved community hospitals) builds goodwill that helps them improve their own conditions as well—goodwill that is necessary as Covid-19 conditions push more nurses to the brink.
Now these same conditions have expanded the discussion yet again, ratcheting up conversations about the broken health care system. The pandemic drove New York Governor Andrew Cuomo to take control of the state’s hospitals, so that public and private facilities would be “sharing staff, patients, and supplies.” For Keefe and her colleagues, the moment was ripe to consider a real national health care system.
The United States, Keefe noted, spends more money on health care than any other country in the developed world, yet its health outcomes are among the worst, and the pandemic’s ravaging of the country is a brutal reminder of this fact, with more than 400,000 deaths from Covid-19. It is a moment, Bazel said, when most of the country is focused on health care. Oddly enough, it is also a time when the workers finally feel acknowledged and supported by the public. Our patchwork health care system was built on the expectation that these workers, nurses above all, would cover the gaps with self-sacrifice. But what if the system instead was built on nurses’ understanding of what it takes to provide care?
“Imagine if the response at a local level and even the national level was being figured out by health care providers, in conjunction with health care providers around the world and with the communities and patients and families being affected by this,” Keefe said. “We are finding out that all these things that seemed impossible, it is really just a question of political will, because the money is there and the capability is there.”
As the Covid-19 vaccine rollout began, a Queens nurse became the first person in the United States to be vaccinated. It signaled, perhaps, the beginning of the end of the pandemic, but for rank-and-file nurses like Keefe and Bazel and so many others, their struggle is far from over. When the fog of the pandemic clears, they will still be fighting to patch the holes in our health care system with something other than endless self-sacrifice. After all, as Keefe asked, if we can spend over $3 trillion on stimulus, why can’t we fix the health care system?
