Dan Zuberi, Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients.

Reich, Adam

Dan Zuberi, Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients (Ithaca: Cornell University Press 2013)

THE FUTURE OF THE labour movement in the US and Canada almost certainly depends on its success in service industries like health care and education. Within such industries, workers and those who advocate on their behalf are wise to link claims for better wages and working conditions to broader conceptions of the public good like better patient care and higher quality schools. This is clearly Dan Zuberi's intention in Cleaning Up: How Hospital Outsourcing Is Hurting Workers and Endangering Patients, the title of which makes the connection that he works to substantiate over the course of 125 pages. The broad claim of the book --that the way a society treats its lowest-level health care workers in turn impacts the health of the society--is an important and provocative one.

Zuberi begins with the spectre of rampant hospital-acquired infections, which rose sharply in British Columbia immediately following the widespread outsourcing of ancillary hospital staff in 2004 (though has declined slightly since). He argues that there is a "largely overlooked connection between deteriorating working conditions in hospitals and the increase in hospital-acquired infections." (6) The greatest strengths of the book are in the rhetorical links it makes between workers' and patients' wellbeing, and in its passionate advocacy on behalf of low-wage hospital workers.

Given his interest in the relationship between the outsourcing of hospital ancillary staff and the increase in hospital infection rates, however, Zuberi employs a somewhat counterintuitive research design. His research consists of interviews with hospital ancillary workers and other health care professionals, along with participant observation (although the participant observation goes largely unmentioned in the book), all of which occurred between 2007 and 2011. Zuberi recruited preliminary interviewees at union meetings and used snowball sampling among these interviewees to broaden his sample.

This design would not necessarily be an issue if the book's goal were to enrich our understanding of the experience of ancillary hospital work in an increasingly market-driven environment. But the book's central argument hinges on the link between outsourcing and infection rates. Thus, the fact that the research starts three years after outsourcing becomes problematic. While we learn a lot about the struggles that hospital workers face in the contemporary environment, it is almost impossible for the reader to discern the extent to which these problems have worsened since outsourcing. (Zuberi often reports statistics from his interviews--i.e. 74 per cent of the workers he interviewed said the job negatively affected their physical health (46)--without discussing how these statistics might be different from those that would have been found before outsourcing, and without discussing how this statistic is influenced by his admittedly biased recruitment strategy).

Given the data to which Zuberi had access, another potential strategy would have been for him to compare the experiences of workers, and hospital infection rates, across different hospitals that used outsourcing in different ways or to different extents. This would have helped him to draw clearer conclusions about the relationship between outsourcing and workers' experiences, and between each of these and hospital-acquired infection rates. Yet while Zuberi recruited interviewees who worked at different hospitals across Vancouver, he spends no time discussing variation in workers' experiences by hospital.

The more general problem with this book, however, is that it is simultaneously so narrow in focus and so broad. By staking his argument on the connection between the outsourcing of ancillary staff and hospital-acquired infections, he sets himself up for questions he is not prepared to answer. First, does outsourcing actually lead to increases in hospital-acquired infections? Zuberi's interviews do not help to answer this question. On this question, in fact, the most compelling evidence that Zuberi marshals is not his own. Instead, he cites several reports on hospital outsourcing in Vancouver by Robert Stanwick and Nancy Poliak, among others--as well as a robust health policy literature, all of which support the conclusion that Zuberi repeats here.

Second, if outsourcing does in fact lead to increases in infections in Vancouver, by what process does this occur and how generalizable is this process? In the case of British Columbia, Zuberi argues, outsourcing led to a radical reduction in ancillary staffing levels and cutbacks in the training of these staff, a fragmentation of communications systems between in-house staff and the outsourced ancillary staff, and an almost complete lack of accountability for the contractors. Zuberi implies that these are all inevitable results of outsourcing: "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." (63) This likely contains some truth, but it is almost certainly an oversimplification. We might imagine counterfactual cases in which outsourcing could lead to the hiring of more expert cleaners, the implementation of more streamlined communications systems, and a hospital administration that carefully monitors the services for which it contracts. It would likely not surprise us, for example, if an external corporation implemented and administered a hospital's electronic medical records systems in a more efficient and effective way than an in-house team. Large and unsubstantiated generalizations --"outsourcing is incompatible with the needs of complex institutions" (122)--do not help us better understand the ways that market forces interact with bureaucratic systems such as the hospitals in Vancouver.

If Zuberi's narrow claim is unsupported by his evidence, his sweeping discussions of hospital-acquired infections, on the one hand, and low-wage work, on the other, feel irrelevant--the non-overlapping areas of a Venn diagram of which the book's argument sits at the intersection. The book discusses a wide variety of causes of hospital infection that have little to do with the outsourcing of ancillary workers: among them too little hand washing among all hospital workers, the overuse of antibiotics, a lack of administrative monitoring and reporting, hospital overcrowding, contaminated catheters. Likewise, we learn quite a bit about the hardships faced by of low-wage workers that bear only indirectly on hospital safety or cleanliness.

Despite these limitations, Zuberi's analysis succeeds in highlighting the importance of hospital cleanliness for the prevention of hospital-acquired infections, and in suggesting (if not proving) the ways that improving the wages and working conditions of low-wage hospital ancillary workers might improve patient outcomes. While this reader was hoping for a more rigorous proof of the connection between worker and public well-being, Zuberi's book nevertheless makes an argument we cannot afford to ignore.

ADAM REICH

Columbia University