Nickel and Dimed Public Health

Nickel and Dimed

Public Health Nursing

Book review and public health commentary:

Nickel and dimed: On (not) getting by in America

Book review and public health commentary:

Nickel and dimed: On (not) getting by in America

Barbara Ehrenreich's book Nickel and dimed: On (not) getting by in America has become a contemporary classic: through a radical act of experiential journalism, Ehrenreich challenges the notion that the minimum wage is enough for a human being to live on, in America today. By actually living the life of three, low-wage workers and recording her experiences, Ehrenreich hopes to demonstrate that the minimum wage is not a living wage. By approaching the life and work of an average worker in a hands-on fashion, rather than merely doling out a salary to herself while living at home, she also gains insight into the physical and psychological as well as the economic stresses of being poor.

Ehrenreich chooses three types of low-wage, low-skill jobs to experience. In Florida, she initially works as a waitress, but is forced to take a second job cleaning motel rooms, just to stay solvent. The fact that the waitressing job provides some food enables her to scrape by for a short period of time, but eventually the anger of the customers and the mistreatment of her colleagues (one of whom is fired unjustly for stealing) drive her to leave. Ehrenreich then moves to Maine, a place which she characterizes as a region of white poverty: she works as a housecleaner there, supplementing her income serving food at a nursing home. Ehrenreich paints a portrait of a community that is polarized between the haves and have-nots. Women with barely enough to eat clean the marbled kitchen tiles of the wealthy. Finally, Ehrenreich descends to her worst job -- that of Wal-Mart, where she is forced to endlessly stock shelves for little pay -- and almost no benefits. Efforts at unionization are cruelly thwarted by the world's biggest retailer. Unlike her job as a waitress or even as a maid, working at Wal-Mart provides her almost no solidarity with her fellow employees.

Professional response

From the point-of-view of a public health provider, at first Ehrenreich's story may seem to have few features of interest -- Ehrenreich never discusses going to the doctor, after all. But that is what makes her tale so relevant. None of her jobs have healthcare benefits. And Ehrenreich notes the fact that, as an older woman, she was only able to keep up the pace of her two-job shifts because of a lifetime of relatively good benefits, healthcare, and the ability to exercise and eat properly. Many of her colleagues were not nearly as lucky. In Maine, Ehrenreich describes women working as maids cleaning beautiful kitchens, even though they are old, infirm, or so weak with hunger they can hardly stand. One woman, Holly, who is pregnant with a sprained ankle, seems to have barely enough food to survive, and the little money she has is used to feed others in her family. Not only is management indifferent to the sickness of the maids who are laboring at physically demanding work, when the women complain are told to simply pop an Excedrin and 'get on' with it.

This is another important feature of Ehrenreich's tale: workers who work in low-wage jobs cannot even easily get a sick day to recuperate, much less afford to go to the doctor if they have no or only meager insurance. Their bodies are treated like disposable commodities, to be worked hard until they cannot work anymore -- many of the waitresses in Key West barely last one day, it is grimly noted, because of the strain the job places on one's back and feet.

Another interesting fact uncovered by Ehrenreich is the low level of health literacy, even basic literacy, amongst her colleagues. While hardly unintelligent, Holly has trouble reading directions and basic words. A low level of functional literacy is linked to a low level of health literacy. For example, someone who cannot read well will have difficulty understanding the nutritional labels of food and medicine. Ehrenreich notes how girls who must work for hours cleaning houses often select a bag of Doritos over a sandwich for lunch, presumably because the Doritos are cheaper and taste good.

Of course, for the workers at the lowest end of the pay scale, Doritos or the free burger Ehrenreich gets as a waitress for lunch is an undreamed-of luxury. Lunch might instead be some store-brand hot dog or hamburger rolls. Public food assistance is distinctly unhelpful -- like the bag of food containing candy and Hamburger Helper but no hamburger, Ehrenreich dryly observes, to 'help' it out. Ehrenreich, although health-conscious, often finds herself eating fast food like Wendy's, simply because of a lack of time and cooking space and the fact that the food is filling and cheap. The poor are often criticized for eating fattening food, not cooking, and not getting enough regular exercise. Ehrenreich's struggle to stay healthy is a potent illustration of why this is the case: she is forced to live in efficiencies with almost no access to cooking implements that are located in dangerous areas with little access to places to move around. Simply getting to work is a challenge.

The psychological toll of low-wage work is also devastating: worker's opinions are not sought by management. Even when cleaning, something the workers presumably do in their own homes, they are instructed how to clean according to the company format. Although sometimes they are forced to be entirely autonomous, such as when Ehrenreich must manage the care of an entire ward of severely incapacitated patients, although she has no medical training, their commitment to their job is never honored or recognized. The only exception can be found in some of Wal-Mart's forcibly cheerful corporate slogans, which are transparently designed to convince workers not to unionize.

Community health issues and application

Basic aspects of the healthcare system are clearly broken. Workers need to have greater access to community health centers and also information about how to obtain benefits for themselves and their children, if they are eligible. Food stamps and charity-based food services are seldom used by the workers in Ehrenreich's book, because workers are too confused about how to get them or cannot take time off of work to explore their support options from public assistance. The example of Holly also indicates that the culture of America might encourage workers not to seek help because of the value placed upon independence, hard work, and pride. But Ehrenreich stresses that these individuals are working hard: they often are trapped in an exhausting spiral of poor housing, poor education, and poor opportunities and cannot improve their circumstances.