An Interview with Pat Armstrong

This transcript has been edited for clarity and length.

IAN MCKAY: The Wilson Institute’s Syndemic Series is honoured to welcome Dr. Pat Armstrong, Distinguished Research Professor in Sociology at York University and a Fellow of the Royal Society of Canada, one of Canada’s most distinguished feminist scholars, and, by general consent, our reigning expert on  long-term care and its many challenges….

A lot of my comments will focus on [her collection] The Privatization of Care, co-edited by Hugh Armstrong, truly a seminal contribution – a transnational contribution that looks at Nordic as well as North American countries, the result of a seven-year, six-country project, conducted by a team of more than 50 students, post-doctoral fellows, and research associates – it’s a must-read if you want to grasp the real world of long-term care, transnationally….

My first question: A major theme of your work has been what you have called “affirmative action” for corporate ownership.…You find that privatization has taken many forms from outright corporate takeover to stealthier processes of outsourcing that you and Suzanne Day discuss in your book on laundry services.^[1] Can you tell me what set this process of privatization in motion?

Armstrong: Capitalism. The falling rate of profit, as I’m sure everyone here knows, contributed heavily to the support for neoliberalism and the intensified search for new places to invest. It became obvious in the free trade agreements, when they talked about Canada’s health care system as an “unopened oyster,” and a place to invest. There was a whole lot of talk about the ageing population… The [growing numbers of] older people in the population came to be talked about as “the gold in the golden years,” if I can put it in those terms, a great place to make money…

One of the obstacles was the way the care was structured. In long-term care, the tradition has been a combination of not-for-profits (often churches or particular groups like the Ukrainians or the Italians), or government-owned… or privately-owned (but those tended to be small, mom-and-pop operations that owned one home and the home itself would be small.) This changed significantly especially under Harris [Mike Harris, Ontario Premier, 1995-2002]… because this is when we see [corporations] move in…One way they were really supported was through the competitive building process that really favoured them significantly, having the experience and the personnel to do it, but also their… capacity to get capital… The second thing was, Harris removed some of the regulations, another classic neoliberal approach. He increased the number of private rooms you could have for which you’re able to charge more money. They also really significantly removed the requirement for staffing levels…and a number of other regulations that just have made it easier for them to operate… in terms of the staffing which, of course, is the major cost in long-term care (or any healthcare, for that matter). He helped them along, and the result is now 58% of our homes are owned by the for-profit sector, most of them by big corporations like Extendicare, or Sienna, or Chartwell.

MCKAY: I’m going to… channel my inner Milton Friedman – and… put forward the four big arguments that a neoliberal might make for this transition. So, I’ll just lay them out and then we’ll go out through them one by one. First, a neoliberal would probably say that innovation and efficient management in this sector has been beneficial to the public, in the public interest. Second, a neoliberal would say that work reorganization has made homes healthier and offered quantitative guarantees of quality. A third argument would be that public/private partnerships and the new paradigm of public management offers us higher standards of accountability – we know what’s going on in these homes far better than we used to. And four, that neoliberal eldercare with its competitive business model offers members of the public choices that they didn’t have before….Now people can choose much more freely what kind of eldercare they want.

So, let’s start with number one innovation and efficient management. If Canada is confronting spiraling health care costs and a “gray tsunami” that threatens to bankrupt the entire system, don’t we need fresh thinking and adventuresome entrepreneurs like Chartwell, like Extendicare, like Sienna, capable of making the overall system more dynamic and effective? Doesn’t the new public management approach replace unresponsive bloated state bureaucracies with lean, effective, business-like enterprises meeting growing demand for seniors’ care – with effective market competition, improving quality, and saving money?  

ARMSTRONG: Well, I think the first response is to quote what Jim Stanford likes to say is the technical term used by economists: bullshit. I mean none of these things apply…

We’re talking about what are more commonly called nursing homes, we’re talking about places that provide 24-hour nursing care. They shouldn’t be mixed up with retirement homes. Because Extendicare, and Chartwell, and Sienna own both, the ads you see are for their retirement homes (for which you pay all of the costs — it could be as much as $120,000 a year, before you start to pay for much of your nursing care). So, let’s just be clear we’re talking about nursing homes, which in Ontario receive significant funding. You pay fees, but those fees are carefully controlled by the government. So, it’s important to know what we’re talking about, right?

 In terms of innovation, I’ve seen none… I don’t think they can point to a single innovation that has come from them. In fact, some of the interesting stuff that has been happening in terms of long-term care are [in the public sector]. For instance, there’s a municipality not far from Toronto that decided to build a new long-term care facility and combine it with market-based apartments and assisted living, so the market-based apartments help subsidize additional kinds of care in the nursing homes and in assisted living. It means that they can have a much broader range of services, etc. If there’s innovation happening, there isn’t any claim that it’s exclusive to the for-profit sector.

In terms of efficiency, all of the homes get the same amount of money. It’s based on the intensive care needs of the residents, but it’s virtually the same, so they’re virtually getting the same kind of money. So, it’s not saving the government a penny to have the for-profits there – nothing – because they get the same kind of money, whether they screw up or not.

In terms of accountability, well let’s go to the staffing question… At the center of capitalism is the need to sell more and pay less. If they’re going to make money, that’s partly what they need to do. You will hear it said that, “Well, we can’t save the money on staffing, because in Ontario we get our money in what are called envelopes.” So, you get a nursing envelope and if you don’t pay that on staff, then you have to give the money back… We do know that the staffing levels are significantly lower in the for-profits than in the not-for-profits and even lower than in the government-owned.

…And one of the ways you can make money on staffing, in addition to maybe exaggerating it… is squeeze out money in terms of staffing levels… So, they have lower staffing, and they have a higher proportion of their staff that’s part-time – another classic move of neo-liberalism in terms of precarity… Overall, in long-term care, less than half of the staff work full-time.

MCKAY: …My second “Miltonian” point: well,  what’s wrong with doing more with less? You’re talking about the flexibilization of labour. It gives managers and workers ample scope for innovation, holding them accountable to higher standards of care. We have these new wonderful [measuring] techniques. What’s wrong with that? What can you say against flexibility?

ARMSTRONG: Flexibility for whom? [Often] you have very little time to care… There are so many things that have to be checked off on the list, that have to be done, there is virtually no flexibility for the people who provide the care. And therefore there’s very little flexibility for the people who need the care either.

MCKAY: Your book has wonderful descriptions of workers in these homes who are saying: “I would love to spend some time to chat but there is just no time. I have to fill in a form for whether they have dessert, I have to fill in a form for every little tiny thing – but filling in all those forms means that you really can’t spontaneously interact with anybody.” Treating people humanely and compassionately means sitting down and talking to them, getting to know them,… but in this model there’s so much emphasis on just quantifying everything.

ARMSTRONG: And making it “efficient.” To go back to your question, an “efficiency” doesn’t necessarily mean care. We have long argued, in this project… that care is a relationship. To build a relationship, first of all you need continuity and staff, which means you have to have a much higher percentage of full-time staff, and they have to have some security and to continue to work with the same people over time, so they get to know them… In addition to the talking, it’s the all the other aspects of being human… [Careworkers] have to rush them to get dressed. So, instead of helping them dress themselves (which gives you a sense of dignity and a sense of control over your life), [staff] dress them, because you’ve got to get them to the table. But also, you dress them in something that you can throw in the washing machine and boil. So, you don’t even get to wear the clothes you want, let alone pick out the clothes. Just think of what it would be like in the morning if someone came in and said, “I have 10 minutes to get you into the dining room and you’ve been sleeping and you can’t easily move your own body or get your body out of bed – and you have to be dressed.”

It’s one of the reasons we did the book on clothes and laundry. We didn’t start out this project… but it just became so obvious how important this was.

So, yes, it’s about time, it’s about building that care as a relationship. and it’s about chatting – and it’s about a lot of other things, too.

MCKAY: You’ve covered the third point, as well, so… on to my last “Miltonian” point. (The name of his best seller is Free to Choose)… Why shouldn’t everyday Canadian taxpayers have the right as consumers to choose whatever kind of home they want, at the price they’re willing to pay? What’s wrong with the free market in healthcare, especially if it’s saving taxpayers money?

ARMSTRONG: We’ve got a free market in retirement home care right now. If you’ve got the bucks, you can pay. We have the free market in home care — if you’ve got the bucks, you can pay… [But, with respect to funded facilities] you have very little choice because the wait lists are so long.

It’s another form of privatization: to continue your public services, but make them less and less accessible. So, you force people into the for-profit sector. And that’s what we do now. Those people who have the money can buy the care right now… Inside long-term care, many people and many families pay what are usually called private companions, to supplement the care in long-term care, because there isn’t enough care there.

MCKAY: A point you raised that really undercuts the “choice” argument is how little time families have when suddenly it’s an urgent question of putting your elderly parent in an institution – you have, maybe, a week or 10 days to make the decision, [or] you’re… bumped down the queue. In many ways, it’s not an open market at all, is it? It’s a forced choice.  

ARMSTRONG: I think… what we have to do is stop reifying the private home as the absolute ideal for the entire world. We have to remember there are an awful lot of people who don’t have homes. Or, we have to remember what feminists have said for a long time: homes aren’t necessarily havens in a heartless world. As we’ve learned during this pandemic, they can be lonely, they can be violent, they can be a problem rather than a solution.

How can we make congregate care a positive alternative? That’s what our focus should be, and I don’t think we should do it on the basis of who can pay.

MCKAY: I’m going to abandon my Milton Friedman schtick and go back to my own voice. What I really thought was especially fascinating about your work is the insight it gives us into what Antonio Gramsci called the “integral state.” By that, Gramsci meant, essentially, the ways in which society is integrated into a widely shared philosophy and practice of rule by its ruling class. So, in a neoliberal integral state, dedicated to creating market-oriented consumers, there’s a diminishing sense of any obligation to create empowered citizens …[and an ideal of] market-oriented individuals empowered to make their own decisions about their health. The term you and Rachel Barkin use for this is “responsibilization.” Beatrice Mueller in Germany speaks of “education for markethood.” Very rich concepts. I wondered, as I read your most recent work, if we aren’t up against a very comprehensive philosophy of time, property, competition, individualism, and ageism much bigger than the question of who owns nursing homes. Isn’t it a question of contesting a multifaceted, hydra-headed philosophy of neoliberalism that extends almost into every aspect of our lives?

ARMSTRONG: Well, we have for a long time talked about the various forms of privatization, and we argue that one of those forms is the privatization in our heads, [according to which care of the old is about individual or family responsibility]. And, of course, by “individuals” we usually mean women… As [Roy] Romanow said in his Royal Commission study of the future of health care in Canada, “it’s a matter of values.” We have to decide, on the basis of values, what we think we need, not on the basis of some notion of austerity.

I think that what [the crisis in long-term care] demonstrated to us is the cost we can pay for [trying] save money in this sort of way.

I don’t think getting rid of for-profits will get rid of the problems. I think it’s a step in the right direction. But we have to get rid of this other stuff in our heads – start thinking about care as a relationship…How can we live humane lives in congregant care – or outside it?

MCKAY: In many ways the crisis of 2020 has seen the bills for this neoliberal experiment come due,  hasn’t it? In many ways, this seems to be a pattern that has gelled… since the 1970s. Now, I think we’ve had the opportunity in 2020-2021 to say, here are the real implications of what we’ve been doing. Isn’t [there] a kind of cross-Canada revulsion against what has been done to our elderly that will spark something, that will spark the value-oriented change you’re talking about.

ARMSTRONG: That’s my hope. For a long while now. I’ve been saying I’m really afraid [once] we get the vaccines, the death rate goes down, [then] long-term care moves off the front page… Will we move on to something else?

And my other fear is: they will say, “Yes, everybody should be looked after at home.”  When we say “care” at home, we [generally] mean care by women. We’ve also seen that during Covid. What it means for women to have to provide more and more care.

Most older people do live at home now and most of them, when they need care, get that care from a woman. It’s not that men don’t do anything, but the primary care, the primary stuff like body care and food and laundry, is done by women. Men do more of the outside stuff, they do more of the more flexible stuff.

That’s partly why we started to work on the care economy – to try and argue [that] our primary investment should be a care economy. We need to think of the care infrastructure like we think of the physical infrastructure of bridges and buildings and those things that we invest in.

MCKAY: It goes back to some of those old debates within political economy about mode of production… Feminist scholars like you said, “You also have to think about social reproduction and the generation of people who are actually going to fill these social roles,” pointing out that there’s a deeply entrenched tendency to discount that, not even notice it. So, [those who assume] that all this work can be done in the home [are] not really asking, “Who’s going to do the labour?”

ARMSTRONG: In terms of old age, if we’re going to be serious about people living at home, we have to make sure the sidewalks are safe and clear, we have to make sure that it’s not Walmart but stores in the neighbourhood – the 15 minutes that the American urbanists have been talking about (you can walk within 15 minutes to everything you need in order to survive). We have to make all of our buildings accessible, not just physically but socially as well. We have to start rethinking, right from the beginning, if we’re really going to transform long-term care.

MCKAY: My last question… Can this wrenching crisis become a moment of fundamental change for Canada’s elders, and who will bring it about?

ARMSTRONG: Us… It has to be all of us… I think that it’s one of the things that makes me hopeful. I get tons of emails from people [asking], “What can I do?” And I think people are starting to do it. They’re starting to do it in health coalitions, they starting to do it in in environmental groups, they’re starting to do it in family councils and nursing homes. I’m hoping that there is more engagement.

But it’s not going to happen if we think that… suddenly the government’s going to wake up at whatever level and say, “Oh yeah, care economy.” I have some hope that there is another kind of democratization going on and that there is more engagement. The other thing that has been warned about for a number of years: the baby boomers getting old, they’re not going to go quietly into the night. That that may be good.

QUESTION FROM THE AUDIENCE. I wanted to talk about racialized feminist care-work economy… I’ve been thinking about that a lot lately about the overlap of Covid and the long-term care crisis and the care diaspora. The global care diaspora and the ways in which racialized migrant workers have been slotted into making this work… at great cost… It’s not just women, it’s racialized women and it’s the ways in which neoliberalism also feeds this worldwide care diaspora.

ARMSTRONG: There’s absolutely no question that, especially in long-term care, you’re talking about racialized and/or immigrant women (and not very many Indigenous women). You are talking about a labour force, especially in the urban areas, that can be [made up of a] majority of racialized and/or immigrant women.

And there’s no question that, when you look… within those occupational categories, they’re at the bottom, and you’ll find a higher proportion of racialized or immigrant women in home care than in long-term care, and home care is the lowest paid, the most precarious, [with] the worst conditions… It’s about women, too – a massive undervaluing of the value of this work.  

That’s especially seen to be the case of women from the Philippines, of women from certain countries.

So absolutely, it’s a critical point and it’s something that we have to directly address.

The other question is:  there’s always been a debate about whether you are,  in drawing on other countries for your care labour force, robbing those countries, especially if… their training and education is provided there. So, the big expense happens there… Is that fair?

The ILO and the OECD at the end of 2019 produced a report on the care labour force (especially in terms of long-term care) and they said, unless you significantly change the valuing of this work and change its organization, that there isn’t going to be a labour force. You can’t keep just deciding that the way you solve this problem is to bring in people from other countries to do this work. You have to do something about the work itself and thus, the respect you pay to all of the people who work in these jobs.

QUESTION FROM THE AUDIENCE: I just wanted to touch on the fact that many people in long-term care situations also have disabilities. People with disabilities have been disproportionately impacted by the whole pandemic… The level of social disposability that’s apparent at this moment is quite disturbing.

ARMSTRONG: This is a critical question for sure. There are a significant number of younger people in long-term care. We talk… as if everybody’s over 85 and that’s simply not the case, in part because we’ve… cut off so many other options. In this study we did for the City of Toronto, I interviewed a woman who was just about to turn 65… She said, “My wheelchair is paid under the disability envelope and when I turn 65, I won’t be eligible for that anymore. I don’t know if I can keep my wheelchair.” The level at which this is stupid… is amazing to me!

I have yet to meet anyone who said, “I really plan to go into a long-term care home when I get older, when I can no longer look I look after myself.” If we can never imagine ourselves there, we’re not going to do anything about it… What are our options? And why aren’t we talking about what we want that to look like?

One of the things I hear a lot is, “Well, why don’t we build these [homes] out in the country?” And I hear residents say, “I don’t want to watch the grass grow. It’s bloody boring…” Also, some of these for-profits have bought places in the city, valuable real estate, and are interested in building their new home out in the country… Workers can’t get there; family members can’t get there. We were in one home in Canada where there was a lovely stream in the back and the staff put out food so the deer came out and ate. Every once in a while people would go watch, but how long could you watch a deer? Instead, they would sit on the side that was the parking lot, and watch the people and shopping center across the road because it was that activity.

MCKAY: One thing that you and André [Picard]… agree on is ending [what he calls] “elder apartheid.” Why do we assume that it’s a good thing to warehouse people – to categorize them in a particular way and warehouse them? Even people with dementia can profit from being part of a wider social network, of being not shoved aside. You have instances from your Nordic countries of people with dementia being given knives to work with in kitchens and being allowed to help. In other words, the whole idea should be to break down some of these artificial categories and start treating people like human beings.

ARMSTRONG: And  also mixing up the populations… Putting grade seven and eight classes in into a long-term care residence, so that you have younger people moving in and out on a regular basis. We were in one place in Sweden where they had floors that were student residences.

We don’t need to segregate our elderly population or our younger population who need a full-time support into either the country or into places that are only for people of a certain age… I think [we need] more desegregation in general, in terms of how we provide care, and we have to be innovative.

In Norway, [in one home]  they had a music program… In this place, all of the staff were trained to use music in various ways. They had a choir that performed publicly of people with dementia who were basically non-verbal. They could sing together in a choir and do that in a way that that was certainly pleasing to the public to hear… When people came into the nursing home, [the staff] found out what their favourite music was… They also put the words of their favourite songs… above their beds, especially for people who  were spending a lot of time in their bed or had a lot of the care provided in their bed. We know that there’s a lot of violence in long-term care against care workers. They dramatically reduced the violence.

If you don’t have the time, if they’re really rushing you, or if they don’t have the time to help you to the toilet – it’s no wonder people lash out. Well, what [the staff in Norway] found was, when they were providing care in bed, they would… start singing with their favourite lyrics… It was something that both changed the atmosphere in the place but also… built on the capacities that people had and gave them the satisfaction of exercising their capacities in a different way. They also, in Sweden, paid… residents when they did things like empty the dishwasher, and cleaned up the kitchen, and stuff – so that it was recognized as labour.

MCKAY: I wanted to especially thank you for ending on this hopeful note… It’s so good to reflect on positive, possible alternatives that we could fight for in the new world that’s emerging around us. Thank you so much, Pat, especially for this path-breaking work. It deserves a wide readership. I hope it gets one.

Pat Armstrong talked with Syndemic on 18 June 2021.

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[1] Pat Armstrong and Suzanne Day, Wash, Wear and Care: Clothing and Laundry in Long-Term Residential Care ( Montreal and Kingston: McGill-Queen’s University Press, 2017).