A Call to Unionize Healthcare Workers

In this exclusive video, Eric Reinhart, MD, a political anthropologist, psychoanalyst, and medical resident at Northwestern University in Chicago, discusses the recent resurgence of labor movements among the U.S. healthcare workforce, and argues that unionization can benefit public health and change the "exploitative labor practices" of hospital systems.

The following is a transcript of his remarks:

I recently published an article in JAMA Network Open called "The Political Education of US Physicians." It was an invited commentary about an analysis that was published in the same issue about the cost of housing relative to residency compensation structures and how the vast majority of residency programs in the U.S. that are evaluated in the study -- many hundreds -- impose a rent burden status on residents, which means they're paying over 30% of their income for rent.

What the study also showed was a very large increase in the cost of rents over the last 20 years, while resident physician compensation has actually dropped during that same period when you adjust for inflation.

This joins a growing body of literature that -- although each of the content pieces are really important -- I think the general focus of the literature is much more important, which is a confrontation with the reality of exploitation within our healthcare industry. This is true, of course, not just for physicians and -- frankly, not even most of all for physicians -- but for nurses, for techs, for janitorial and custodial staff.

Exploitative labor practices have been the norm within the U.S. healthcare industry for a very long time, and this is reflective of the general value systems that they uphold, which are profits over people. The New York Times has written a whole bunch of pieces about this. I myself have been trying to write about this, and also a segmentation of health from broader policy determinants like, for example, labor conditions and the force of the labor movement.

In order to understand where we are now in the relationship between healthcare and labor, we have to put it into historical perspective. It's very important to recognize that when you had a period of de-industrialization in the U.S. and a lot of really good union jobs were lost -- in part because of policies that fostered those losses as the economy was outsourcing a lot of these to other places in the world where labor was cheaper -- what you had between the beginning of Ronald Reagan's presidency and now is a halving of the number of people who are in unionized jobs in the U.S. During Ronald Reagan's presidency, about 20% of the U.S. public was in a unionized position. Today, it's about 10%.

Since the recession of 2007/2008 -- and then also the pandemic accelerated this as well -- there's been a resurgence in interest in labor movements and labor politics. This is not just for defending the rights of workers and the conditions under which they're working -- which exposed a lot of, for example, service industry workers to profound COVID-related risks -- but also as a mechanism for political organizing for policy change writ large.

This is why I think the resident unionization movement that we're seeing in U.S. hospitals right now is so important. It's not just about countering the exploitation of residents and fellows, which is important. It's about imagining the ways that we can organize together to produce policy shifts that affect not just us, but broader communities and the policies of the institutions for which we work, and then an aggregate of the cities in which we work, of the states in which we work, and the nation.

There are a bunch of models for this, of how unions in different industries have made core to their platforms not just the interests of their members, but the interests of the communities around their members -- the interests of the communities that their members serve.

So, for example, here in Chicago where I am, we have the Chicago Teachers Union, one of the most progressive unions in the country. They have been organizing for a very long time, not just to improve the conditions of the schools that the teachers work in and the labor conditions of the teachers themselves, but also the conditions in the communities of a lot of very underserved neighborhoods in Chicago -- dispossessed, frankly, neighborhoods where people have not had access to mental health services. There has not been stable housing. We have a very large unhoused population, which affects children who are going to schools. We have a lot of kids who are going hungry, families that are going hungry.

So when the Chicago Teachers Union is imagining what its priorities are, it's not just thinking about how many sick days can we get covered, what are our hours going to be? We're thinking about how we produce conditions for thriving for the students that we're working with and their families. Their organizing platform has been to bring communities into the goals of the union itself.

If you're part of a union and your union is organizing with other unions and you are advocating on behalf of communities around your hospital and you can say, "Hey, my hospital has really bad energy practices," this is just a microscopic example, but I think it's actually really important, it's meant to illustrate the broader point. You can force changes to those policies so that the U.S. healthcare industry is not producing 25% of the greenhouse gas emissions of the global healthcare industry, which is a major contributor to deaths from respiratory disease and cancers, etc.

There's a Lancet study that estimated, I think it was 88,000 deaths in the U.S. every year are caused by the emissions produced by our healthcare industry. That can be changed. We have horrific energy practices. Europe doesn't have the same degree of energy intensity in their hospitals, etc.

This is the kind of political issue that no clinician can address on their own and that has massive consequences for their patients [and] for them. But as a collective, you can assert power so as to force changes that entrenched interests simply are not going to make unless they are forced to do so.

I think thinking about how we can use labor organizing within healthcare to not just talk about the political determinants of health, but effectively organize to shift policy -- to shift the politicians who are representing us, to really bring national policy into line with public health imperatives -- is one of the most important duties that we as caregivers in the U.S., whether that's as nurses, as techs, as doctors, as community health workers, I think it's one of the most important things we can do.

There is very widespread resistance to labor politics in the U.S. and to shifting labor norms in the context [of] hospitals, where you have a very intense hierarchical medical culture that, frankly, features a lot of hazing.

If you're going to confront this and say, "Hey, we really need to change our labor practices, we need to change how we organize this professional culture," you're going to get massive resistance because people feel personally implicated. You are essentially saying that they have failed to produce policies and cultures that are conducive to health, that are conducive to equity, that are conducive to anti-racism, [and] that they are personally responsible, in part, for massive, widespread preventable death. I mean, that's what it ultimately is. That's the downstream consequence of all these things.

That's very hard for people to stomach. That's why you have, for example, at Harvard when the residents and fellows were unionizing, you had intense opposition. It's not just because of the economic interests of the hospital that they mounted opposition and tried to bust the union formation there. It's because their moral identity is challenged by the idea that things should be otherwise and they haven't made them otherwise, despite decades of commitment of their entire lives to this field.

So, how do we bring these people on board?

I think it's a huge challenge. And I think we have to recognize that we're not always going to succeed and that any genuine political struggle entails conflict. It entails, in the crudest terms, ideological enemies. We have a lot of ideological enemies to necessary shifts in the U.S. health landscape if we're going to produce systems that actually effectively care for patients, that are actually equitable, and that don't rely on exploitation of workers, which has deleterious health consequences as well.

So I think it's important to try to not get caught in big-tent politics where we can erase our differences, which is a very common political strategy in the U.S. You see this particularly in the Democratic Party: "Let's not go too hard."

For example, Obama, when he had the opportunity to push for legislation of abortion rights when he got into office, decided not to do it because it would be too divisive. The Democratic Party is constantly doing things like this, and this is reflective of a general perception of politics where the best thing to do is to push for unity rather than conflict. Unity is most easily achieved, in most instances, by reaffirming the status quo and not making powerful people feel threatened.

So I think within healthcare, where we have a culture where you're very much discouraged from producing any kind of confrontation with people who are above you in the hierarchy, our bigger question is: are we going to have the courage to fight powers that be in order to shift things?

I want us to not be vindictive. I want us to be capacious in how we imagine solidarity and who we can bring into this fight, but not compromise on the principles and the convictions about the historical injustices that remain ongoing now.

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