Abstract
I was in Paris when the pope announced his retirement. Later that week, a small band of French feminists staged a noisy demonstration in Notre Dame, banging on the great bells displayed in the cathedral’s central aisle and celebrating Pope Benedict’s resignation as a blow to entrenched Vatican patriarchy. “Those crazy women,” sniffed my French host, “what do they hope to accomplish?” Having just concluded Salimah Valiani’s examination of the impact of patriarchy on global health care, “Rethinking Unequal Exchange: The Global Integration of Nursing Labour Markets,” I understood their frustration. From churches to hospitals, institutionalized sexism has far-reaching consequences.
Valiani’s accessible analysis makes a major contribution to our understanding of the forces that shaped modern health care. Her subject matter is broad and multilayered, and the reader is well served by the varied perspectives she brings to the discussion. As a multidisciplinary academic researcher, trade union policy analyst, and feminist thinker, Valiani uses the profession of nursing as an exemplar of how economic manipulations transformed the delivery of care. Specifically, she analyzes the impact of nursing migratory trends in three countries—Canada, the Philippines, and the United States—and examines how capitalistic conquests and the weakening of trade unions have transformed health care in general and “caring labor” in particular.
To understand fully how we arrived at our current state of fractured and fragmented American health care, a basic understanding of international economic theory is requisite. For those who are deficient in this knowledge, Valiani provides a basic tutorial. The concept of “unequal exchange” arose in the 1960s. Its genesis provides the focus of her research questions, “What does international nursing migration in the late twentieth century reveal about restructuring in the world economy, and how might we rethink 1960’s theory of unequal exchange in light of liberalizing labour markets and the essential role of female caring labour in capitalist production?” (Preface)
The burgeoning fields of big pharma and sophisticated diagnostic technology contributed significantly to the inflation in costs that beset health care in the 1970s. The result was, in part, the growing corporatization of caring as community hospitals were “acquired” by large systems, ushering in the “centralization of capital” within the hospital sector. Health care institutions sought ways to cut costs, and as the largest segment of the professional workforce and the most predominantly female, nursing became the prime target. Valiani traces how the response of Canada, the Philippines, and the Unites States formed a microcosm of these seismic shifts. To increase profits and reduce costs, hospitals aggressively sought new “customers,” thereby increasing nurse–patient ratios without additional staff. Nursing unions were targeted, and staffing concerns went unaddressed. In the United States and Canada, nurses fled the hospitals and sometimes the profession itself. The Philippine government responded by tailoring its nursing education to meet the needs of this emerging market. These newly trained nurses arrived in the United States and Canada often with temporary status only and were mandated by their government to return a hefty portion of their earnings to their country of origin. The ramifications of this “unequal exchange” dictated by the needs of a capitalist market continue to have serious and largely unaddressed consequences, not the least of which is the “persistent undervaluing of caring labour” (p. 18).
Lest the reader lose sight of the feminist implications of these health care trends, Valiani argues that “[T]he beginnings of health care commodification in the [U.S.] may be traced back to the first decade of the twentieth century, when the American Medical Association, the American Pharmaceutical Association, the National Association of Retail Druggists and the American Hospital Association came together to seize the delivery of health care away from women. Prior to the twentieth century, women delivered health care in the domestic sphere using past knowledge, medicinal herbs, and, by the 1860’s, concoctions produced by the patent medicine industry” (p. 44). Valiani’s work provides an essential link among the economic forces, political responses, and inbred sexism that dominate the health care industry. Ring them bells!