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The Duty to Strike

Health workers have long been wary of job actions that disrupt their patients' care. But the Irish nurses strike shows how strikes can actually defend public services and win popular support.

A group of nurses in Ireland, 1946. Willem van de Poll / Wikimedia

In an Ireland where many workers have not yet seen the benefits of postcrisis recovery, it is nurses who have come into the forefront of the fight against austerity. Over the last two weeks the unions representing nurses have mounted gradually extended strikes to heap pressure on the government to resolve their demands over staffing levels and pay. Polls suggest the nurses’ action enjoyed a phenomenal 74 percent public support.

The strike has certainly had a major effect. Across three days of walkouts on January 30, February 5, and February 7, 2019, all nonemergency hospital services were canceled, affecting more than 80,000 patients. The dispute then seemed likely to escalate, as the Irish Nurses and Midwives Organization (INMO) and the Psychiatric Nurses Association (PNA) threatened three consecutive days of direct action. Such a strike would have brought an overstretched health system to its knees.

Despite the intensity of the conflict, public opinion remained solidly on the nurses’ side. As a sign of this overwhelming solidarity, tens of thousands of people marched together with nurses in downtown Dublin on February 9. Two days later, unions suspended their action, as the Labour Court made a proposal for new pay scales and promotion opportunities, to be voted on by union members in March.

In many respects, this was a traditional labor dispute: it revolved around pay and working conditions, and it followed the regular route of escalation and then suspension after the Labour Court’s intervention. The tools used by the striking nurses are also familiar to anyone with some idea of trade unionism. Nurses formed picket lines around hospital buildings, chanted slogans, waved union banners, and displayed placards with demands.

Yet the fact nurses took such action — the biggest strike in Ireland in recent years — was itself surprising. In the not so distant past, public sector professionals were held back from industrial action by a combination of prohibitive legislation and a certain conception of their own professional ethics. To quote Harry Eckstein, medical professionals had a “deep inhibition towards anything that smacked of trade unionism,” and nurses’ associations used to hold a similar position.

Today, we see how much that has changed. In advanced economies, a growing share of labor protest now comes from the unusual suspects. Teachers, nurses, and even medical consultants are engaging in conflict with their employer — typically meaning the state. In taking strike action, workers long inhibited about using the labor movement’s repertoire of protest tactics are reenergizing the fight against austerity as a whole.

Proletarianized Professionals

That such an imposing anti-austerity action came from nurses is especially surprising when we consider the long-term history of their professional associations. Although the INMO was formed in 1919, it kept its distance from the trade union movement until the end of the 1980s and it only called its first strike action in 1999. Since then however, it has played a prominent role in wage struggles and has become one of the most vocal opponents of austerity.

For decades nurses’ associations had accepted a subordinate position within Ireland’s interest-group politics, in which they were also under the conservative sway of the Catholic Church. This was married with a gendered view of nursing as a charitable feminine activity — one in which the acceptance of low pay went hand in hand with workers’ subordination and sense of devotion. Individual nurses may or may not have internalized this view. Yet their associations long adopted a stance wary of industrial action.

Today, such views seem outmoded, especially as workers are subject to the contradictory pressures of professionalization and proletarianization. Education, health care, and social service employees are required to perform more and more complex tasks and to make high-responsibility decisions hour-to-hour. In the case of nursing, this process has gradually freed the profession from its subordination to medical doctors: for instance, Irish nurses have recently been authorized to prescribe medication.

Yet this upskilling has not been followed by an expansion of available resources or professional independence. On the contrary, these new (semi-)professions are often forced into bureaucratic structures with rigid managerialism and are not rewarded financially. In recent years, they have become one of the main targets of austerity. Public services are highly labor-intensive activities — wage costs can run as high as 60–85 percent of operating expenses — and wage cuts thus offer the biggest budget savings.

An emphasis on the need to suppress public sector wages also gels with the neoliberal talk of “competitiveness” so dear to small open economies like Ireland. In this narrative, the public sector is the “sheltered, protected” sector that is isolated from global market pressures and poses a threat to the performance of “exposed” sectors, as it offers employees excessively high wages. More specifically, it is argued that public sector wages are not in line with productivity.

This statement is doubly problematic. Productivity measures make little sense in sectors where outputs are not sold on the market. And productivity is by definition lower in activities which are built around real-time, face-to-face human interaction, such as education or health care. Often, low productivity (a low ratio of students to faculty or patients to nurses) can even be taken as a sign of quality. Indeed, Mariana Mazzucato’s recent book The Value of Everything convincingly argues that national statistics systematically underreport the value of public sector activities, for example by not acknowledging the crucial role that health and education play in sustaining the private sector. Despite these flaws, the idea of the unproductive public sector informs key government decisions and EU policy recommendations and has become even stronger in the wake of the global financial crisis.

Irish elites insist that the country’s economic recovery after the crisis owed to responsible fiscal policies, and not the windfall revenues that Ireland enjoys as a financial and service hub for global corporations. The official mantra is that austerity worked: and in the Irish case, austerity mostly meant slashing the public sector wage bill. Employee compensation in the public sector fell in every year but one between 2008 and 2014 (by 7 percent in 2009 alone). Some of these cutbacks rested on collective agreements, which unions grudgingly signed up to when threatened with even harsher unilateral measures. These agreements also included the promise of reversing cutbacks once the public finances were stabilized. In recent years, discussion has thus turned to restoring public sector pay levels. However, the current version of the Public Service Stability Agreement, in force since the beginning of 2018, still prioritizes fiscal discipline over addressing the serious injustices in the treatment of the public-service workforce.

Who Bears the Burden

Covering the entire public sector (from clerical work through law enforcement to health care and education) this agreement enjoys the support of general public sector unions (such as SIPTU and IMPACT), who as a rule avoid full-scale confrontation with the government. Since the public-service professionals’ unions (including nurses) would have risked getting nothing by going it alone, it also entered the deal.

But most nurses were left unsatisfied with the pace and the methods of pay restoration. Irish health care — similarly to many other countries — is facing a recruitment and retention crisis. Many of the highly qualified Irish nurses continue the tradition of emigrating for higher wages and better working conditions to Australia, Canada, US, or even to the UK. Others defect to the private sector. In the end, staff shortages mean intensified working life and a strong risk of burnout for those who do stay in the system. It is in this context that the nurses decided to launch this year’s campaign over pay.

The public debate between the government and the nurses’ unions has revolved around the questions of what constitutes responsible behavior in this context. The government insists on the alleged need for sustained fiscal responsibility. Taoiseach (prime minister) Leo Varadkar went even as far as to argue that the Irish state cannot afford public sector pay rises because it needs to save money in preparation for a hard Brexit. “I have to be Taoiseach for the whole country,” said Varadkar during a debate in the Irish parliament. His statement is a reminder that when a government is in dispute with public sector unions, it will try to portray itself as the guardian of public interest against an irresponsible special interest group. The government’s credibility in responsible budgeting was however undermined by revelations that the building costs of a new children’s hospital (still under construction) had overrun by more than €400 million, a fact which the minister for health attempted to cover up. By comparison, the deal that is currently on the table to resolve the dispute with nurses will cost a maximum of €35 million per year.

Beyond the question of fiscal responsibility, if public-service unions are to win such disputes they have to be able to convince citizens that they are not only fighting for higher wages but also for better-quality public services. Indeed, public support is the most effective weapon in the unions’ hands. A public sector walkout can do little financial damage to a government, as taxes continue to be collected while the payment of wages is suspended; at the same time, unions are supposed to cover the lost remuneration of striking members from their strike funds. Strike organizers also must fend off claims that they are putting the lives of patients at risk. While emergency and life-saving services were fully operational during the nurses’ strike, more alarmist claims also started to appear in the Irish media.

Yet the unions are themselves alive to this PR battle. The Irish Nurses and Midwives’ Organization had gained a reputation for taking patients’ concerns seriously, already before it called the present strike. Since 2004, the INMO has been collecting data on how many patients were lying on trolleys in the accident and emergency wards of hospitals. This simple measure has even been accredited by the Health Service Executive and INMO successfully uses it to highlight an aspect of hospital underfunding that is more dramatic and can more easily mobilize public sentiments than waiting list figures alone. During the strike, nurses’ leaders also invoked the notion of patient safety, arguing that current staffing levels are unsafe. They made explicit the causal chain starting with low salaries, leading to emigration and labor shortages, then to excessive working hours and the exhaustion of the remaining staff.

While patient advocacy groups abstained from taking sides in the dispute, the level of support that nurses received during their Dublin rally and the overall favorable media coverage suggest that nursing unions’ framing strategies were successful. A survey conducted before the first day of action on a sample of 1,000 people found that 74 percent of the public supported the strike. Besides, as of February 7, 2019, more than 68,000 people expressed support by signing an online petition “calling on the government to take action and raise nurses and midwives’ pay to ensure safe staffing.”

For decades, trade unions in the Global North have had to put up with accusations of economic irresponsibility. Economic and political elites blamed trade union militancy for the stagflation crisis of the 1970s, even though the causal links were never proven. In the wake of the neoconservative assault of the 1980s, union leaders internalized this blame and wherever they could, they went into social pacts that preserved their institutional status but brought little to their members materially. The 2008 crisis caught a trade union movement whose membership was decimated and whose center of gravity shifted towards the public sector. Political and economic elites used the post-2008 austerity also as an opportunity to deliver another major blow to the movement. However, they also triggered a new radicalism from public sector unions that can be one of the first signs of labor movement renewal.

Many observers (even those on the Left) believe that the shifting of labor protest towards the public sector deepens the image problem of trade unions as irresponsible special interest groups. The main message of the Irish nurses’ strike is that this is not necessarily the case. Trade unions still have the capacity to earn a reputation as responsible actors, even without shying away from taking radical action in defense of wages and public services.