Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients by Dan Zuberi (review)

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 Pollak, among others – as well as a robust health policy literature, all of which support the conclusion that Zuberi repeats here...