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the first stage of the argument as a simple care by physicians and hospitals from market
labour process can now be regarded as a vast forces, making it universally and freely avail-
number of distinct activities, which may able as an attribute of citizenship, rather than
often appear not to be part of care at all, as as a commodity. However, drug and equip-
immediate emotional and body work is ment costs outside of hospital, long-term
divided off from other activities, such as lab- institutional and community care, dental and
oratory work, food preparation or adminis- vision care, physiotherapy, and a whole
tration. All of these activities are part of the range of other mainstream and alternative
overall production of health care, but the treatments and therapies are covered only
division of labour causes some to be regarded partly or not at all. They must therefore be
as care and others as distinct from care. purchased directly or indirectly via private
How could the administration of a hospital insurance, by the individual. Health care is
be regarded as care? Yet, try to imagine how thus only incompletely decommodified as an
care could take place in a hospital without object of personal consumption. Health care
forms of coordination of activities and also costs states tens of billions of dollars,
resources. Seen in isolation, the work of an which are spent on buildings, equipment,
accountant or of a member of the cleaning vehicles, pharmaceutical products, and espe-
staff in the hospital does not look like care, cially on wages, benefits and professional
which one associates rather with the work of fees. Labour power and means of production
nurses, for example. But all of these activities are largely, but certainly not entirely, com-
are part of a larger process, which gives them modified in health care. In an era of fiscal
their overall purpose, meaning and definition. restraint, there have been enormous incen-
Health care at this level of the analysis tives for governments to cut back on the
comprises different spaces, temporalities, areas that are fully insured, by shifting care
hierarchies and networks. Hospitals are cure- to ‘extended health services’, for example, by
oriented, heavily unionized (at least in the moving patients out of hospitals and provid-
case of public hospitals in Canada/ ing them with community care. In the words
Québec), dominated by centralized manage- of Nona Glazer, there has been a massive
ment and a hierarchy of professionals; at the work transfer from professionals to non-pro-
opposite end of the spectrum, volunteers fessionals, from regulated to unregulated
bring warm meals to housebound people and workers from waged to unwaged workers
individuals care for their kin. The social divi- and from hospitals to the home (Glazer,
sion of care is the basis of multiple, intersect- 1988, 1993). Several studies have shown the
ing relations of class, status and power within negative impact of this cascading process on
the state, between the state and its citizens, women who bear the lion’s share of the
employers and employees, producers and con- burden of unwaged care work (e.g., Aronson
sumers, professionals and non-professionals, and Neysmith, 1996; Gagnon et al., 2001;
regulated and non-regulated workers, waged Guberman et al., 2005).
and unwaged workers, as well as between Under the pressure of cost containment,
regions, sectors and institutions. The dynam- the health care system can be seen to have
ics of conflict, competition and cooperation, gone through stages analogous to those of
which were merely latent at the earlier level service industries in general. With the rise of
of analysis, now occupy a central place in the mass public and private health insurance sys-
discussion. Gender runs through all of this as tems that strove to bend the professionals and
an omnipresent faultline. major equipment and drug suppliers to their
In Esping-Andersen’s terms, publicly will in the creation of mass produced serv-
insured health care is an instance of decom- ices at the lowest cost (‘fordism’), the health
modification (Esping-Andersen, 1990). In care system underwent change from the rule
Canada, for example, it protects access to of a somewhat paternalistic elite of mostly