Not long after COVID-19 started spreading in the United States, stories began to appear about the anguish unfolding in the nation’s hospitals, not only among the tens of thousands of patients arriving in emergency rooms short of breath, but also among beleaguered caregivers. Some of these accounts focused on problems that have long plagued the medical profession: burnout, stress, anxiety. But others examined more novel challenges, such as the ethical dilemmas facing nurses and physicians forced to decide how to apportion scarce medical resources to critically ill patients. Should the last ventilator in the ICU go to an elderly person at greater risk of dying or to a mother with two young children? Which patients should be admitted to a hospital that was already overwhelmed? Making these freighted decisions in harried, compromising circumstances could cause lasting psychological trauma, warned a June 2020 article in Scientific American. It could also result in moral injury. Doctors were trained “in treating one patient at a time,” not in doing triage, a bioethicist quoted in the article observed. “I think the real reckoning is going to come when this is over,” said a psychiatrist named Wendy Dean, who had cofounded a nonprofit to study the effects of moral injury in the health-care profession.
The moral and emotional wounds that dirty workers sustain are, like the workers themselves, unseen—“hidden injuries” that go unnoticed. Not so with medical professionals on the front lines of the coronavirus pandemic, whose travails made national news. Prominent publications not only reported on the ethical predicaments these caregivers were forced to navigate. They also invited them to tell their stories in their own words. “The collective soul of front-line health care workers is slowly and silently decaying with no rescue in sight,” a physician of internal medicine wrote in USA Today. “We need help carrying this massive weight because we are weary.”
The fact that medical professionals were given such platforms was surely not unrelated to their social prominence. It was also a product of the fact that what they did was seen as indispensable to society, even heroic. This was never more the case than during the pandemic, when physicians and first responders were hailed for putting their own health at risk to provide urgent care for others. Like home health aides and other so-called essential workers, they were performing a function that other people depended on and that was necessary to keep society running.
The idea that dirty work might also be necessary to society is more unsettling. A defining feature of such work is, after all, that it causes substantial harm, either to other people or to nonhuman animals and the environment. To a person like Toby Blomé, the Code Pink activist I visited in El Cerrito, it seems obvious enough that inflicting such harm is profoundly unnecessary. The high-tech killing conducted by drone operators happened not because targeted assassinations were essential to national security, Blomé told me, but because of the outsize influence of the military-industrial complex, a cabal of for-profit contractors and special interests that distorted America’s priorities and profited from its endless wars.
But the truth is that the drone program doesn’t just serve the interests of military contractors. It also serves the interests of a disengaged public that doesn’t want to think too much about the endless wars being fought in its name and, thanks to the drone campaign, doesn’t have to. The dirty work of conducting targeted assassinations can be left to people like Christopher Aaron and Heather Linebaugh, with few questions asked. Likewise with the dirty work of warehousing the mentally ill in jails and prisons in a society that has failed to fund mental health services. This arrangement benefits not only for-profit companies like Wexford and Corizon but also many citizens who are content to have the mentally ill disappear behind bars without dwelling on the consequences. This, too, is work essential to society, solving various “problems” that many of us would like to have taken care of, provided someone else can handle them.
Most of us don’t want to hear too much about such work. We also don’t want to hear too much from the people who do it on our behalf, not least because what they tell us might stir discomfort, maybe even a trace of culpability. I felt this discomfort frequently in the course of interviewing the subjects of this book. When Stephen Stone talked about people who cast judgment on the “country bumpkins” from backwoods towns who got jobs on oil rigs while giving little thought to how dependent their own lifestyles were on burning fossil fuels, I nodded in agreement. Then I drove my rental car back to the Airbnb where I was staying and felt implicated. When Harriet Krzykowski lamented the fact that many Americans saw individuals with severe mental illnesses as “throwaway people,” particularly if they were poor and lacked access to treatment, I shook my head disapprovingly, but later wondered if this was, subconsciously, how I viewed them. I passed such people on the streets of New York City fairly frequently. More often than not, I felt for them, but not so deeply as to keep them in my thoughts for very long.
One reason that even people who are momentarily bothered by such thoughts avoid dwelling on them is that they feel powerless to change them. And, individually, we are powerless to change them. The decision of one person to buy a more fuel-efficient car (or, for that matter, an electric vehicle) will not end America’s dependence on fossil fuels. Handing a couple of dollars to a mentally ill homeless person talking to himself on a street corner will not alter the fact that jails and prisons have become de facto mental health asylums. But collectively, we are not powerless to alter these things. As I noted at the outset, a core feature of dirty work is that it has a tacit mandate from “good people” who refrain from asking too many questions about it because its results do not ultimately displease them. This mandate is important. But it is not set in stone. The attitudes and assumptions that it rests upon can change, and indeed have changed. In the past decade, the punitive sentencing laws that fueled America’s prison boom have fallen out of favor. Although warehousing mentally ill people in jails and prisons is still tolerated, this, too, may change as the backlash against mass incarceration leads us to ask questions about the social and moral costs of the status quo. Attitudes toward industrial animal agriculture have also shifted, even if, for now, this has led more often to a fixation on buying meat that is “organic” than to addressing the deplorable conditions to which workers in slaughterhouses are subjected. So, too, with our reliance on the fossil fuel industry, which more and more people are coming to realize must be phased out quickly for the planet to survive.
The belief that the troubling circumstances we have come to tolerate are impervious to change can itself become an excuse for resignation. It can fuel the kind of apathy that prevailed among the “passive democrats” that Everett Hughes described in his Frankfurt diary. The resignation is unwarranted, because, like most aspects of the social order, dirty work is not immutable. It is a function of laws and policies, of funding decisions, and of other collective choices we have made that reflect our values and priorities. Among these choices is whether to recognize the immense harm it causes, not only to innocent people and the environment but also to the people who carry it out.
The anguish such workers experience may elicit little sympathy from those who feel that anyone who participates in a cruel or violent system must be held accountable for the suffering they cause, even if, afterward, they harbor shame or regret about what they have done. As Primo Levi affirmed in “The Gray Zone,” doubts and discomfort expressed after the fact by oppressors are “not enough to enroll them among the victims.” But Levi also called for judgment of the low-ranking functionaries in oppressive systems to be tempered by awareness of how susceptible we all are to collaborating with power, and by an appreciation of the circumstances that lead relatively powerless people to be pushed into such roles. In contemporary America, the chief circumstance to consider, I have suggested, is inequality, which has shaped the delegation of dirty work no less than the distribution of wealth and income. More privileged Americans are spared from any involvement in such work, knowing it can be outsourced and allotted to people with fewer choices and opportunities. The result of this moral inequality is to ensure that an array of hidden injuries—stigma, shame, trauma, moral injury—are concentrated among those who are comparatively disadvantaged. These moral and emotional burdens have barely factored into the debate about inequality, perhaps because economists cannot measure and quantify them. But their effects can be equally pernicious and debilitating, shaping people’s sense of self-worth, their place in the social order, and their capacity to hold on to their dignity and pride.
Inequality also shapes the geography of dirty work and who is held responsible for it. As we’ve seen, the blame is rarely directed at the companies that profit from it or the public officials who have passed laws and policies that perpetuate it. More typically, it falls on the least powerful people in the system, “bad apples” who are singled out after the periodic “scandals” that shock the public—the same public that spent the preceding months or years ignoring what was being done.
In fairness, one can hardly expect the public to register concern about conditions it rarely sees. Dirty work is obscured by structural invisibility: the walls and barriers that keep what happens inside prisons and industrial slaughterhouses hidden; the secrecy that envelops the drone program; the nondisclosure agreements that the middlemen overseeing the cobalt supply chain are required to sign. These arrangements have had a “civilizing” effect, pushing disturbing events “behind the scenes of social life.” Yet there are limits to what even the most elaborate mechanisms of concealment can hide. In spite of the isolation and impenetrability of institutions like prisons and industrial slaughterhouses, plenty of information about what transpires within them leaks out. The secrecy cloaking the drone campaign has not stopped writers and documentary filmmakers from producing illuminating work about it, nor have nondisclosure agreements prevented NGOs from issuing detailed reports about the cobalt supply chain. The problem is not a dearth of information but the fact that many choose to avert their eyes, not only from dirty work but also from those who get stuck doing it, people with whom they almost never interact and find easy to judge.
What do we owe these workers? At minimum, it seems to me, we owe them the willingness to see them as our agents, doing work that is not disconnected from our own daily lives, and to listen to their stories, however unsettling what they tell us may be. The discomfort may run both ways, of course. The first time I met Harriet Krzykowski, she read me some excerpts from the narrative she’d written about her experience at Dade. The material was wrenching, so much so that her voice trailed off several times. Afterward, I wondered if it might turn out to be the last time we’d speak. Over the next few days, Harriet cried repeatedly during our conversations. But she also thanked me for taking the time to listen. It was intense, she said, but also “healing.” The comment stayed with me, not because I felt I deserved any gratitude, but because it suggested how isolated she felt and how therapeutic the simple act of telling one’s story can be.
The most effective way to help people overcome moral injury is to communalize it, Jonathan Shay argued in Achilles in Vietnam, providing veterans with an opportunity to share their experiences with the public. Medical professionals who risked sustaining such injuries during the coronavirus pandemic were accorded such opportunities from a public that felt indebted to them and that listened to their stories with respect and curiosity. Dirty workers like Harriet were not. As a consequence, the reckoning she engaged in was a private one, unspooling in haunting memories that she had to wrestle with alone. Missing was a parallel public reckoning, the kind of communal exercise I’d watched unfold at the VA hospital in Philadelphia, where people gathered to hear veterans talk about the moral transgressions they had committed in the course of fighting America’s recent wars. Then the audience members spoke, delivering a message all dirty workers deserved to hear. “We sent you into harm’s way,” they chanted in unison. “We put you into situations where atrocities were possible. We share responsibility with you: for all that you have seen; for all that you have done; for all that you have failed to do.”