The health sector is a global sector. The NHS depends on the supply of material from around the world, on workers migrating from the south to the north and on the global exchange of medical knowledge. As workers, we can learn a lot from the practice and struggles of health workers in other countries, from Argentina to France, from the Czech Republic to Germany. We spoke with two friends who work in the health sector in the USA about their working lives and battles.
Introductions
F.: I’ve been a nurse for about ten years. I work in the public health care system. In the US there is basically this huge patchwork health care system: there are so-called non-profit county hospitals, then there are hospitals that are run by the federal government, such as the clinics of the Veterans Administration, then there are many different private companies that run health services. My employer is the county, they run four hospitals, including a psychiatric hospital, but we also have primary care clinics and specialty clinics. Currently I work as a case manager, so I work with people over the long term trying to help them with their social needs. I go to their homes or I go to homeless encampments or I go to their doctor’s appointments with them and I advocate for them. I interface, I go see patients in the hospital, too, where I collaborate with the inpatient staff. So I kind of move between these different settings.
In the US, a lot of health care workers in the public sector are represented by the SEIU trade union. In the private sector, the SEIU represents health care workers who are considered non- licensed or non-registered staff. Nurses tend to be represented by the NNU, the trade union National Nurses United. There’s a lot of other unions too, but that’s one of the big ones. I’m represented by the SEIU. It’s pretty much wall to wall, like the vast majority of the employees are in the same union, now including the physicians at our hospital, which is very cool. So I’ve been involved in my union, we went on strike in 2020 and I helped to work on that. Since October 2023 I have also been working in the Health Care Workers for Palestine formation, organising with healthcare workers from all different institutions.
C.: I am a medical dosimetrist, which is one of those very niche roles that popped up with a greater and greater division of labour in health care. I work in radiation oncology as part of the medical physics team. I went into this job in order to do organising in health care. My background is in physics. Mainly cancer patients come to the clinic, they’ll have a CT scan and a doctor will mark the area of treatment, the tumour volume, the areas of potential disease spread and prescribe a certain amount of radiation. A dosimetrist takes that and runs all of these programs to calculate how to best deliver the radiation to that area while minimising the impact on healthy tissue. These are instructions for a linear accelerator, which is the machine that actually delivers radiation. It gets checked by a medical physicist and then delivered to the machine where the radiation therapist actually treats the patient. My job is not really patient facing, I am mainly sitting at a computer. A nice thing since the pandemic is that a lot of this has shifted to remote work. So I’m hybrid, so I work usually two days from home, three days on site. But that differs according to hospital, some hospitals require dosimetrists to be entirely on site, some hospitals have their dosimetrist work fully remote. That’s been a really big change to our profession since Covid.
I was doing travel work before, because of how the US healthcare system works. When Covid hit I was working at a really big cancer centre that suddenly had many fewer patients because people were postponing non-essential treatments during lockdown. They started doing a lot of furloughs and sent workers home. At the time I was classed as a ‘per diem worker’, which is like daily contract labour, even though I had worked there for three years and was scheduled full time. I had research responsibilities and teaching, and administrative responsibilities, but still, as a per diem worker I had no real contract, no benefits, no paid time off, etc.. It was completely precarious.
I was furloughed and that’s how I became a travel worker.
Regional differences and workforce composition
C.: In the US there’s this huge health crisis and a huge need for health care. The local differences are enormous, so a lot of workers engage in travel work through agencies. You work for an agency, the hospital pays the agency and then the agency takes a certain cut, around 30% of wages. Wages of agency or travel workers are much higher than wages of permanent workers. The agencies do very little in my experience. I actually contacted hospitals and asked if they needed travel workers, so I set everything up, but still had to go through the agency. I was getting around $120 an hour, so you can imagine what the agency charged the hospital. Travel workers are a huge proportion of workers in many hospitals, sometimes half of the nurses on a ward are travellers. They have no institutional connection, there are no relationships between people. Just here for a few months and then moving on. With the labour shortage it’s hard for management to get people to stay on full time. I was staying in an Airbnb in California with a nurse from North Carolina. She would just come over to work for like a few weeks at a time because she could pay her bills in North Carolina with that little amount of California traveller pay.
F.: There’s a big geographic dynamic. Because nurses in California are paid very high and nurses in the American South are paid very badly. But the cost of living is low in the American South, high in the northeast, in the west. So there’s a ton of people who travel from the south to work in the west. Nurses in California start their career at 50 to 60 Dollars an hour and make 100 Dollars once they have been doing it for a while. Travel nurses make 120 Dollars an hour, plus there might be a stipend for housing. A lot of the travel nurses are newly qualified nurses. In nursing, travel nurses are less likely to be the specialised workers. It’s actually hard to replace ICU nurses or specialised nurses. I think agency work is kind of reactionary because it individualises people, but sometimes it is the only option for recently graduated nurses. Very few hospitals have training programs for new grads, but you could get a job in an agency without any training. A lot of agency workers are also working as scabs when there’s a strike.
These divisions between general and specialised nurses also impact the dynamic around strikes, because there’s laws that restrict our ability to strike in health care, at least to strike legally. So, the employer has the right to get an injunction against striking nurses and demand that we leave certain specialised nurses in the hospital and that they don’t strike. During the strike in 2020 we tried to use that injunction in our favour, because we knew there were certain people who were going to cross the picket line. We demanded the right to choose who would be staying at work and we chose the people who were going to cross the picket line anyway. We gave them jobs within the hospital, and we put union t-shirts on them.
In terms of the divide in wages and working conditions between California and the southern states you can see that the average registered nurse salary in Alabama in the Deep South is about $60,000 per year, whereas in California it’s a little bit more than $120,000 per year. California is highly unionised. California’s the only state that has an enforceable law that restricts the number of patients you can have as a nurse. In the South, you might have a very large patient load. If you’re in the E.R., you might be in charge of eight or more patients at a time. Where here it would be restricted to two. The nursing ratio law in California depends on acuity, but 5:1 is the highest amount of patients you could have at the lowest acuity within the inpatient setting. There is a 1:1 or 2:1 ratio at the ICU level. The law came to pass through lobbying by one of the large nursing unions. But we tend to understaff the role of health care or nursing assistants. In the collective contract of our hospital it stipulates the ratio of nursing assistants, too – but that’s just within my institution, not the law. There’s a lot of tension between the nurses and health care assistants about who does the personal care, the feeding, the making of beds. And it’s very racialised here, the nursing assistants are often immigrants. It’s like a class hierarchy. A nursing assistant in a union hospital like mine earns around $25 an hour. It’s an okay wage, but it’s a very high cost of living area. So people tend to commute up to like two hours to get to work. But you can live on it and it has good benefits. Still, you earn much less than nurses.
When it comes to the process of becoming a qualified nurse, there’s still something called ‘licensed practical nurse’ here – that’s in between the two in the hierarchy. Historically nurses just came from people who learned on the job, but now there’s a huge range. I have an associate degree. I have a two year degree, which you get from a community college, basically for free. Versus there’s other nurses who have master’s degrees, and both of us could work the same job and get paid the same within my context. There are also nurse practitioners who have some prescribing powers that don’t get paid much more than nurses in California. It’s a strange setup where there’s a wide range of qualifications. They always say that they’re going to move to where you have to have at least a bachelor’s, which I don’t have. But because there’s always a nursing shortage, I don’t think that’ll ever happen.
Regarding migration, we have a ton of nurses from higher income English speaking countries like Nigeria and the Philippines. It was a good job for African-Americans, it was a way of moving up the economic ladder in nursing. Now we have surprisingly few African-American co-workers. I don’t know if there’s a reduction in the number of African-Americans who are going into nursing in general. There are definitely hierarchies depending on the ward you work on. On general wards there are more immigrant nurses and on more elite wards like ICU or E.R. nurses tend to be like pretty young white women. There are a lot of Chinese health workers in California, too.
C.: I work with a lot of college academics, people with PhDs who work as medical physicists. I think most medical physicists at my hospital are from China. And that’s been the case in most hospitals, a lot of people from China with advanced degrees and some of them work as nurses, as well. When it comes to unions, my hospital, for my profession, we are non-union. But when management studies the wages and benefits, they are looking at the University of California system, where they’re unionised. They’re pegging our wages and benefits to the union hospitals. Because otherwise they’d be losing people to UCSF. So union struggle raises the floor for everyone in the region.
Union struggle
F.: If you have a weak union, then you get these standard 3% pay increase contracts, and they chip away at your rights each contract. If you have a strong union like in my hospital – we had a reformer come in, who ran for president of the union, and we became much more militant. That’s how we went on strike and won a bigger raise and beat back their attacks to take away some of our rights. That happens on a hospital by hospital basis. But we have some states in the US that are right-to-work states that have anti-union laws in place. I worked with some nurses in Wisconsin who were trying to unionise. They were trying to re-unionise after ten years of being non-union. Unlike our hospital strike, that fight was happening much more at the state government level. Ultimately SEIU, which was the union organising, made a horrible decision, which was to try to negotiate it with the governor instead of the shop floor level. They were leading up to a recognition strike, which is not common in the US to strike for union recognition – but ultimately, SEIU sent in their VP to negotiate directly with the state governor, and they’ve won nothing. It’s hard to have a real analysis of national health care worker strike trends just because things are so different in parts of the country. There are a couple of new nurses unions in the South, which is very cool. So National Nurses United, which is basically the California Nurses Association. They’re a fairly militant union. They’ve organised nurses in hospitals in the South, which is very unusual. They’re a very top down union. They’re not a democratic union in any way, but they’re militant and they’re willing to strike. I think that’s something that has a national reach because they’re present in many states in the US.
When we went on strike in 2020 we had two different contracts, one for the nurses and one for the other staff. So in theory, we could have gone our own way as nurses, but because we had this reformer, who had a smarter analysis, we fought for it as one contract, basically. The nurses were more timid and it was harder to win nurses over to the strike.In terms of the actual impact of the strike, I was outside, so I don’t know what it looked like inside the hospital. The bins were overflowing because the garbage folks didn’t cross a picket line, so that was cool. All the bins inside and outside that, it was just to back up. There was a patient who died during a strike at another hospital within the last ten years in the Bay area, because of a scab pushing a medication that was unsafe. So it is unsafe to be in a hospital during a strike. The hospital basically stopped all non-essential services during the strike. Then management got an injunction that required us to leave a certain number of nurses in the hospital, and those were only in certain units, ICU and maternity. We’re not a highly specialised hospital or an academic hospital. So a lot of what we do can be rerouted to other hospitals. A lot of the emergency calls were rerouted to other hospitals. There’s a system within the county for that. So we basically had a reduction in services during the time. And there were experienced nurses who did stay on those specialty units. We gave them these physical strike passes. These passes made you feel official and it made them feel like part of the strike. And I think that was cool because it created more of a sense of solidarity. We were on strike for five days. It was the first strike since the 1990s. There were things I would criticise. For example, our department had to send a petition to union leadership, because we were excluded from the negotiation process.
C.: There was a big strike wave right after the pandemic. I worked as a travel worker and I was around for two strikes. The bigger one was when the nurses union went on strike. And that was an interesting experience. Because the nurses union at this hospital is an independent rank and file union. It’s pretty unique. It’s called Crona, which stands for ‘Committee for Recognition of Nursing Achievement’. It has no paid staff, it is all volunteer nurse run, etc.. I think having the specific special nurses union reinforces the sense of ‘we are a separate professional group’. Having this independent rank and file nurses union hasn’t really led to a huge increase in member engagement or militancy. The strike was pretty cool though. It was the first time they’d been on strike since roughly 2000. Being in a strike that was not run by staffers was a very different experience. I’m used to health care strikes where there are a few staffers who have vests and traffic cones and tell you ‘walk here, say this, here’s your granola bar and your bottle of water’. But this was just a mob of nurses, hundreds of nurses and no one knew how to go on strike. But everyone was out there. A lot of energy. People were super pumped. It was kind of chaotic, but pretty. Because of the rank and file nature of the union, people had a sense of ‘we are in this together, and this is our union’. It was an open ended strike, which is rare. I think they were on strike for ten days. They won big in the strike, which inspired other nurses in LA to strike a few months later. As a travel worker, I actually didn’t know any of the nurses. I couldn’t even tell if the nurses in my department were scabbing. Because I was just passing through and spent time on the picket lines.
The other strike I was involved with was a one day solidarity strike. There is a very small union of engineers, operating engineers like people who run air conditioning systems, etc., that have been on strike for weeks. So the two big unions, the nurses union and the SEIU said we are going to go on solidarity strike for one day. All the rest of the time they’re crossing the picket lines. I was a travel worker at the time. I told my boss that I’m not going to cross the picket line. My boss said, ‘we’ll fire you for that if you do that’. But we have legal rights in the US that individual workers can choose not to cross the picket line and that’s protected. I was the only non-union person to do that and also I was working remotely. So not crossing the picket line from your home was a less thrilling experience. The participation from SEIU members was maybe 30%, definitely not the majority. People didn’t really know who the engineers were. No one from the union came out to talk to people about it. It wasn’t great.
There are political struggles going on, as well. The medical centre where I work is on a university campus. During the organising against the war in Palestine we’ve been trying to build a longer lasting student worker coalition on campus. And yeah, also we talk about anarchist politics, we organise events on campus. I have coworkers who I invite to political events, etc.. Regionally we are in the Health Workers for Palestine – Bay Area group, which has a Signal channel with 700 healthcare workers at the moment. We organise working groups. Palestine organising has been a good place to build connections between healthcare workers in different institutions, different clinics, different professions, different unions. We are trying to organise a BDS campaign in health care. Where I work, it is a giant university and the majority of its money actually comes from the hospital. That’s money generated by us as workers. And there’s a lot of money in endowments and pension funds and and hospital contracts that goes to companies involved in genocide. We emphasise the power that we have as workers.
