(Roughly) Daily

A recent (R)D unpacked a recent Gallup survey of public trust in different professions/ocupations; the undisputed champion, nursing…. to which, friend MK responded: “What’s worse than 24 out of 25 people not trusting members of Congress is one out of four not trusting nurses.”

Edward Ongweso Jr. has a possible explanation– one that has little to do with nurse and all-too-much to do with the deterioration of the system of which they’re a part…

Hello everyone, I’ll keep this bit short this time! Thanks for all the emails with stories about your own experiences in Vegas, with gambling addiction, and with CES in response to my last piece, I read them all and responded to most except the ones pitching me Guaranteed Parlays That Will Hit! Thanks also for subscribing, we’ve jumped a bit and are just shy of 4,400 subscribers. If you like what you’ve read and want to support me further, you can become a paid subscriber for $7 a month or $70 a year. What do you get in return? My undying love, some recommendation posts every now and then, and paywalled essays/rants just as long as this one! Now, let’s get to today’s essay.

I have long believed that one of the greatest threats we face is the proliferation of the on-demand labor platform. The so-called “gig economy” is one of the larger altars to greed and misery in our civilization where millions of people are sacrificed in order to grow Smaugian hoards that are then transmuted into this or that form of power.

My earliest introduction to this was through the work of labor ethnographer and legal scholar Veena Dubal via her law journal article “The Drive to Precarity,” which maps out how militant workers turned San Francisco’s precarious taxi sector into a stable line of work, how companies responded with a wave of deregulation and de-unionization that immiserated workers, and how Uber sealed the deal in returning ride-hail to its earlier insecure form: poor working conditions and starvation wages, with every possible cost (healthcare, fuel, maintenance, etc.) offloaded onto workers and consumers.

Key forms of on-demand labor—namely, ride-hail and food delivery—have proliferated over the past few years, but not because they are particularly profitable or innovative business ventures. Most of them either have no real path to profitability, report dubiously calculated profits, or are operating illegally in hopes of realizing or sustaining them after sufficient lobbying and monopolization and exploitation of consumers/workers. The lazy and incurious view has been that they will grow into profitability, but the transparent reality is that the firms at the vanguard of the gig economy have thrived because they take advantage of a few key phenomena: worker misclassification, algorithmic discrimination, anti-competitive capital-intensive strategies, impressive public relations, robust political lobbying, and shoddy journalism, to name a few…

[Ongweso unpacks the history of ride-hailing apps and of the tactics– some legitimate, some questionable, and some plainly illegal– the industry has used to prevail. Then he turns to nursing…]

… As[ Shawn Carolan, a partner at Menlo Ventures and early investor in Uber] observed, however, ride-hail and delivery are not the only places where the “business model” at the heart of on-demand labor can be applied.

Over the past few years, nursing has emerged as a juicy target for investors and firms eager to liberate entire industries of antiquated regulatory frameworks. Last month, the Roosevelt Institute published a great report on what the application of the on-demand model will mean for nurses and it paints a grim picture. While some hail the emergence of an “Uber for nursing” model as a salve for our nursing shortage, Katie J. Wells and Funda Ustek Spilda detail how these apps reliably degrade working conditions, wages, and care standards.

These apps encourage nurses to work for less pay, fail to provide certainty about scheduling and the amount or nature of work, take little to no accountability for worker safety, and can threaten patient well-being by placing nurses in unfamiliar clinical environments with no onboarding or facility training. On-demand nursing platforms are also using the Uber playbook to lobby state legislatures in an attempt to exempt themselves from existing labor regulations.

I’ll be going through the report section by section to highlight key points as I think the report is phenomenal, but I encourage you to read it in full (linked above).

The premise of the “Uber for nursing” apps is relatively simple: lets use algorithmic systems to managing the scheduling, staffing, and management at medical facilities. For understaffed workplaces looking to cut costs and corners, this is attractive. For nurses and nursing assistants who want more control over their work, this is attractive. But this is especially enticing for investors who drool anytime a firm compares itself to Uber. Take ShiftMed—one of the darlings of this sector and a subject of the Roosevelt Institute report—which has raised hundreds of millions (but declines to share its valuation): $47 million in a May 2024 venture round, $200 million in a February 2023 round, $45 million in October 2021, and an early $6 million boost in an August 2019 round. What concretely are firms like ShiftMed offering to draw financing like this?

After a nurse downloads an on-demand nursing app and submits the requisite documents, they can use the app to indicate their interest in a 6-, 8-, or 12-hour shift at a hospital, nursing home, assisted living facility, surgical center, dental office, or, in some states, correctional facilities. An algorithmic scheduling software program, which is the heart of these new companies, then approves the worker for a shift, notifies both the medical facility and the worker, allows the worker to clock in and out, and, finally, sends a paycheck.

The on-demand nursing industry promises hospitals and medical administrators a different set of controls, namely the capacity to seamlessly staff facilities, reduce manager workloads, and lower labor costs.

On paper, this sounds lovely—the digital disruption of an old rickety system full of middlemen, inefficiencies, misallocation, overcharging, yadda yadda ya. But what’s the reality on the ground? Wells and Spilda found:

… serious safety and health risks for workers and patients. The nurses and nursing assistants who use these apps must pay fees to bid on shifts, and they win those bids by offering to work for lower hourly rates than their fellow workers. Poor internet or cell service in rural areas can cause the apps to fail, resulting in missed paychecks for work performed. These apps also rate the nurses they hire based on facility feedback and internal algorithmic determinations. If a worker must cancel a shift due to sickness or personal conflict, their rating goes down, and they often lose out on future shifts or can be banned from the app altogether. In at least one case, a nursing assistant went into work at a hospital while sick with COVID-19 because she could not figure out how to cancel a shift without lowering her rating. At most hospitals and medical facilities, no orientations are required for gig nurses and nursing assistants. Workers do not know where supply closets are located, how to access patient portals with medical histories and current medication lists, and whom to contact in the chain of command. With gig nursing, there is often little to no continuity of care. Despite hospitals’ attempts to automate nursing, care work is inherently tricky to de-skill and predict. Shifts do not neatly end when the apps say they do as, of course, patients’ health-care needs do not end just because the clock says they should. Human frailty—the essential subject of nursing—defies algorithmic management.

As the report will detail, gig nursing has already proven itself to be an unmitigated disaster and we are still relatively early in its assault on our lethargic healthcare system…

[Ongweso offers more chilling detail…]

… Often the deployment of new technology is used as cover to rollback reforms and regulations that have made old levels of profiteering unrealizable or outright illegal. That tends to be a function of who is steering the design, development, and deployment of said technologies. It is one thing when managers and financiers are in the drivers seat, and it would be another thing entirely if care workers were in control. It is not clear to me why anyone other than nurses should be in control of what sort of technology is introduced into their workplaces, how this technology is designed, why it is deployed, and when it is used. To close out with Wells and Splinda:

“It is important to not lose sight of the enormous amount of skill, coordination, understanding of human vulnerability and frailty, and treatment of patients with utmost decency required to provide good quality care. Technology could provide solutions to automate and unburden the nurses and health-care workers from the everyday management tasks of their work; however, decision-making around such solutions should include the nurses themselves, from design to deployment.”

The gig economy’s metastasis and its threat to healthcare: “Uber’s Bastards,” from @edwardongwesojr.com. Eminently worth reading in full.

* Dag Hammarskjöld

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As we contemplate care, we might send healing birthday greetings to Arthur Nicolaier; he was born on this date in 1862. A physician and bacteriologist, he isolated the tetanus bacterium and developed a successful cure for tetanus.

Nicolaier discovered that the tetanus bacterium lived in soil. Because of its presence in earth, it is responsible for infection from dirty wounds, which was a particularly significant issue in the cases of wounded soldiers during WW I. The toxin secreted by this bacterium, Clostridium tetani, travels along nerves to the spinal chord, causing increasingly severe, often fatal spasms of the head and neck and jaw– from which came the common name of the affliction: “lockjaw.” Thanks to Nicolaier, from 1915 injured soldiers– and any other sufferer– received an anti-toxin.

In the mid-1920s a tetanus vacine was developed. It has subsequently been improved, and has successfully warded off infection in those areas where it is administered. In 2013, it caused about 59,000 deaths worldwide—down from 356,000 in 1990; in the United States, from 2000 through 2007, an average of 31 cases were reported per year.  Nearly all of the cases in the United States occur in unimmunized individuals, or individuals who have allowed their inoculations to lapse.

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