If we're going to talk about how to "scale care" and how not to, then Buurtzorg has to be mentioned[0][1]. It's a Dutch home-care company that was started by nurses who basically got frustrated that managers got in the way of them doing their job. It operates by having a flat organization working with small teams of highly trained nurses, and trusting them to make the right decisions. The result is a low-cost provider of high-quality health-care.
So when the author says care "doesn't scale", they obviously mean "you need a one-to-one ratio of caretakers", which I fully agree with. But what they're also accidentally doing in the process is explaining why creating bigger teams with bigger hierarchies and structures does not appear to increase the efficiency of care.
Some projects do need big teams with hierarchies - even in healthcare. Effectively responding to a pandemic comes to mind. I suspect it's when the core problem to tackle most naturally breaks down like a tree - a hierarchy then mirrors the way the problem breaks down. For some projects, like general homecare, the efficiency sweet spot is a flat structure of autonomous individual teams, because it doesn't scale beyond those teams anyway.
And just like the author concludes, I find that there's something comforting about that.
Thanks for elaborating further what we mean by "scaling".
Couldn't it be said that when organization acquire ranks, it is to solve coordination problems that arise with scale but that in this case, there isn't much that is solved by more organization ?
There's also a different kind of coordination problem.
The incentives of an organization - or at least of a corporation - are to make money and to continue to exist and to enrich and empower the people who control it. But employees' incentives are usually pretty different. Nurses usually get into nursing because they, at least to some extent, want to help people. Engineers get into engineering because they, at least to some extent, want to build something really good. Teachers get into teaching because they want kids to learn. And so on.
If you're the principal of a school, and your goal is for a teacher to teach, you don't have a coordination problem. Most teachers want to do that. But if your goal is for teachers to maximize standardized test scores, or to minimize the number of frustrated parent calls, etc, you do have a coordination problem, because your goals are misaligned with your employees'.
If you're the CEO of a tech company, and your goal is for your engineers to build good software, you don't have a coordination problem. Your engineers want to do that. But if your goal is to maximize conversions, or to ship faster, or to raise money, etc., you do have a coordination problem.
If you run a hospital, and your goal is for your nurses to care for patients, you don't have a coordination problem. But if your goal is to maximize profits, then you do.
It's usually these kinds of coordination problems that managers are, effectively, in charge of enforcing. Their job is not to help individual employees achieve individual employees' collective goals, it's to make employees feel (sometimes truthfully) like their goals are aligned with the organizational goals, or to use the threat of loss of income or work to force them into line.
That sounds about right. If you watched the video then you also will notice that the further up the management chain we go, the more abstract the goals become compared to the most concrete ones that the nurses are dealing with. One could say that if most care work starts and ends with those concrete individualized issues, the cost of handling (or worse, prioritizing) abstract goals is far greater than the benefits that they add.
Compare that to the pandemic response example I gave: that is the kind of challenge where there are concrete problems at individual, city-wide, national and international scale to tackle, and they're all interconnected too. So plenty of those coordination problems you mentioned.
Your reply seems focused on size, but this line caught my attention:
>trusting them to make the right decisions.
I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?
My mom is a (retired) preschool teacher. By the end of her career, she was working for a school affiliated with a large chain, and maybe 1/3 of her time was spent on filling out all the paperwork required by management. That was time she absolutely was not spending with the kids.
My dad is a (retired) doctor. Similar story there. His hospital ultimately ended up associated with a regional health care network, and the paperwork load ultimately got so bad that they ended up having to hire additional staff dedicated to help the actual health care providers fill out all the paperwork so that they could spend more time actually providing health care.
I switched primary care providers over this a few years back. I had a great doctor, but her practice got bought up by one organization, which then got bought up by another, and over time working with her office became a huge bureaucratic quagmire. I switched to a different clinic that's still local (although also chain with multiple locations), and everything's easier again.
The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work.
Well, Buurtzorg is a large organization, it's just that it does not have a large hierarchy. I suspect you're really asking "high-trust" and "large hierarchy". In that case there's plenty of causes to point at. I'll just give a few of the top of my head
First, note any organization that breaks into different departments (hierarchical or not), at least partially does so to let each department "abstract" away the other ones - if you don't have to worry about issues outside of your responsibility, you can focus more on yours. That is actually a form of trust.
In the case of a hierarchy however, that means that each layer abstracts away the layers above and below, and since going up multiple levels in the hierarchy happens indirectly, the further away, the more abstract things become. So that often needs some kind of structure to regain the trust that is lost by dealing with abstract departments - leading to bureaucracy.
On top of that, usually more power resides higher up the hierarchy. That means that without explicit structures to compensate for this, people lower in the hierarchy lack individual leverage to protect themselves against bad decisions made higher up, that may not even be malicious or intentional but just a consequence of the aforementioned abstraction.
Of course, most structures that are created to fix this typically are also abstract procedures, meaning they barely help with our instinctual "I cannot attach a face to this" type of distrust. Bureaucracy can create leverage, but rarely creates trust. Which also explains that quite often, talking to someone in person can make such a difference in being allowed to "go ahead" or not. Because it can provide a more "natural" sense of trust that bureaucracy is supposed to provide but barely does.
Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.
Most healthcare organizations in the US are profit-oriented, sometimes to the detriment of the patients. That is why we have large, unwieldy organizations surrounding the very few people that actually do hands-on healthcare. There’s also the issue of liability – it can be pretty litigious in the US, and companies are frequently wanting to limit their liability, which means having the paperwork to back up their decisions. Unfortunately, it also means they have to restrict their decision-making to a very small matrix.
Legally an organisation is usually exposed in relation to its scale, even if the misconduct was limited to one employee trusted to carry out work independently, the penalty will likely be related to the total size of the company.
The second is if you're scale is large enough that you are considering a significant portion of the employees with some skill in a region, you have a harder time selecting for anything other than "holds a qualification" during hiring. This leads to all sorts of policy to prevent someone with qualifications but less integrity causing issues.
I don’t think it’s that they are incompatible by definition. I think the large organization is a result of low-trust.
A trust-breaking event occurs, so a new form gets added, a compliance process is created with a new team monitoring, etc. etc. Have enough of those and you eventually get your typical, modern healthcare bureaucracy today.
I live in Switzerland and my girlfriend has been working as a doctor (surgery), and it has mostly to do with the politics that come with hierarchy. As in nearly all companies, hierarchy allows politics and favourism to enter the playing field which will attract people that do not act in the primary interest a service should have: ergo, patients.
For example you have leading doctors who prefer not to look at patients, even tho they belong to them (from a specialization point of view), as they are "cumbersome" cases. That often leads to them "ignoring" it for some time until someone else takes over, or completely delegating it to non-fit persons.
It's a huge pain for me to heard this every day, because it literally sucks out any desire to work as a doctor from my girlfriend. At the same time, it's infuriating: we pay a lot each year, and with every year more, for services like this. If I was to ever win lottery, I'd use that money to make my own hospital without all of this crap.
The other companies are also shortstaffed, all healthcare is at the moment, and the bureaucracy layers just keeps humming along ... Buurtzorg is however cheaper, and since you cannot scale the actual care that counts.
Honestly sounds like that's Conway's law, but in reverse. Instead of a project's setup mirroring it's organization, the organization mirrors what they see as the ideal project setup. That's something that I wish more teams were willing to recognize as the best approach; Conway's law isn't necessarily something to be worked around, it's a tool.
Doesn't scale compared to what, though? Because if the comparison point is the more typical modern care-work organization where tasks are divided into a fine-grained categories of "high skill" and "low skill" work, outsourcing the "low skill" tasks to the low-trained workers as an attempt to save costs, then Buurtzorg shows that that approach is not a net savings.
Because Buurtzorg has been shown to have lower costs and higher job satisfaction than its competitors, and the reasons are quite obvious too: the hierarchical outsourcing solution adds extra communiciation costs, administration costs, and similar organizational overhead. On top of that patients are in a situation where they see many different unfamiliar care workers briefly, meaning they do not get to form a bond of trust with any one of them. That is a pretty heavy costs that I don't even know how to categorize.
> There was some pain in that realization. So many of my utopian dreams—what if we could live in a society where everyone can get the food, the housing, the healthcare, the opportunities for growth that they deserve—come from a place of wishing that we could live in a world where people are cared for.
I'd like to offer some comfort to the author on this score. Food, housing, healthcare broadly... while these are all aspects of being "cared for" by society, they aren't all care in the individual sense you describe. The food system is different from homecooked meals; the housing economy is different from the handsome breakfast nook your family DIYed into their home. We can build systems which scale and make it possible and economical for individual care to happen.
> The food system is different from homecooked meals
This is a good point, and everything I've heard from parents says that it's parents, not children, who identify home-cooked meals with care. Children notoriously prefer prepackaged industrially processed food over whole foods prepared with care and love. In order to feel cared for, all children need is to trust that the person caring for them will make sure they get enough food when they need it. Food quality has nutritional consequences down the line, and at some point a child that is fed pancakes every day will gain the ability to look back and regret how they were raised, but it doesn't prevent a child from feeling cared for in the moment.
if you'll forgive my prior snark, some people successfully involve the children in the cooking. When this is done, the children seem to prefer the home-cooked because they are part of the cooking and they are part of the feeding/providing to others.
Don't underestimate the human desire to provide value to the tribe, it runs deep in the evolutionary make-up.
> Children notoriously prefer prepackaged industrially processed food over whole foods prepared with care and love.
In most cases, this is probably due to the care givers training their children to prefer that kind of food because they don't make many home cooked meals.
I don't even know if it's true, though. When I was a kid, the best food in the world were the home made meals my grandmother made, especially on the holidays. Remember as a teenager telling my Grandma her meals were better than any restaurant I had ever eaten at, and meaning it in all sincerity.
Children notoriously prefer consistent meals over diverse ones, home cooked or not. The issue with serving blueberries for example is that each blueberry is different. My mother home-cooked for me a boiled egg and rice porridge every morning, and it was that consistency that associated me with care.
Often, it's the act of preparing the meal by hand rather than pressing a button on their hypothetical Food-o-matic that makes the biggest impact. We can certainly scale the provision of needs otherwise. I agree with the author on their assertions about what it means to care and actually connect with people.
I'm not talking about food preparation, but food systems. E.g. look up the concept of a food desert. Preparing a meal by hand is one thing; having access to quality affordable ingredients is another. A food desert is what you get when the system that would enable care is deficient.
And even in a "food oasis" with adequate quality, yes, if you yourself cannot prepare a meal, or have nobody to do that for you, that's a failure of a different kind.
Although it’s theoretically possible and theoretically economical for individual care ‘to happen’, it doesn’t in practice for the housing economy. If anything it’s decreasing year by year on average.
Especially when you look at construction quality, the average quality of say new built condos in any major city has gone way way down since the 90s.
Of course on average condo designs have on average gotten fancier with quirkier architecture, and building codes have gotten more complex, so maybe it’s not due to builders caring way less, but the end result is shoddy work either way.
Edit: And the average home buyer has no method of separating out all these confounding factors, so it boils down to a single congealed mess.
About housing: I have a few ideas as to why, weirdly none of which overlap with yours.
1) I think part of it is due to our ability to fine-tune the limits. Before, if a company wanted to pass an inspection, they had to be really confident. There were going to be some expenses that in theory they could have avoided if they were better capable of measuring where the line between 'safe' and 'unsafe' was. The end result was buildings that were more safe than strictly required. But now we can get closer to the line, and so buildings are engineered at the edge of safety.
2) Of course, survival bias plays a role here. Who remembers all the crappy buildings that just vanished? It's the same reason we look at old toasters or mixers or what-have-you and say things were so much better-made in the past - all the crappy cheap toasters, mixers, and houses are gone now.
3) Also, as extreme weather has happened more frequently, areas all over are seeing weather different than what they were designed for. Given that the average temperature in Oregon in July (the hottest month of the year) was typically around 65 degrees Fahrenheit[1]. For the past few years it has generally hovered in the upper 60s. The hottest temperature ever recorded in Oregon before 2021 was 107 degrees Fahrenheit[2], and typically there were one or two days a year that crossed one hundred degrees -- occasionally five, more often none. In 2021, it hit 116 degrees. Since 2021, there has not yet been a year without 4 or more days over a hundred. And, of course, this pattern is repeated all over the world. Houses are being built for one set of extremes and averages and getting another.
Maybe it doesn't in America. Nor here in Australia. Some European cities are showing that better is in fact possible by strongly supporting co-operative housing sectors which are better for residents. But that would break the American taboo against government intervening usefully in private markets for human rights (in this case, shelter).
Anyway, my advice to the author was that systems can enable care at scale. Not to say that our current systems do.
Edit: to be more explicit, I'm suggesting that some approaches to the housing sector in some parts of Europe amount to care that scales; society and governments have decided that housing is a right, and have enacted policies to approach that situation. Conversely, a "we don't care" approach also scales very well with the opposite outcome.
>We’re pretty limited when it comes to care. In any given moment, you can only really care deeply and individually for one person.
Absolutely. Society tends to assume that people are interchangeable units and that 'care' is a commodity which can be dispensed evenly as if from an industrial nozzle in a food factory. So we have 'care homes', 'daycare', 'care packages'. We are enjoined to be more 'caring'.
But the reality is that love, which is what we're really talking about, is dyadic.
i.e. between two individuals. That's how it works and how it effects its magic.
A patchwork of dyadic connections is what we may hope for and build.
Yes, it points to how hard & expensive any government attempt to backstop the traditional parental model of care actually is.
The earlier the intervention the better.. and consistency is also incredible important. But you can spend incredible amounts of money just to get a slightly worse outcome than what was going to happen on its own. As a wealthy society we must do something to help those in need, especially children who are in the situation of no fault of their own. But it's not clear our current methods work.
You can also generalize this problem to the healthcare industry as a whole. Costs go up much faster than the rest of the basket of goods & services citizens pay for, and they don't understand why.
The underlying reason is that - care doesn't scale. You are essentially (directly or indirectly) paying for someone's (doctor, nurse, etc) time. We have not gotten much better at making care more time efficient in the field, and in many cases it has gotten worse (more paperwork/electronic record entry time/etc). Everything else we buy is the product of using automation to replace labor, making labor more efficient, or making labor cheaper (offshoring / simplifying so less training is needed / etc).
> >We’re pretty limited when it comes to care. In any given moment, you can only really care deeply and individually for one person.
The evidence very strongly points the other way, IMHO:
Almost all people care deeply and individually about many others, starting with their families - spouse and children are a clear and I think irrefutable example of deep caring and love for multiple people. And for most, also siblings, parents, grandparents, and some or even many other relatives.
And outside of family is friends, co-workers, etc. Many healthcare workers care deeply (depending on the meaning) about their patients. Fundamental human empathy enables us, if we choose, to see people as individuals and care about them, even people we meet briefly on the street. I've learned to do it and I'm not superhuman.
Obviously we know people experience these things. Why is it important - to what ideology and why - to insist empathy and love is so limited.
I'm not claiming that we can only love one person, it's just that the nature of love is unique to each dyadic relationship; they're not commensurable.
Yes, I may show empathy and respect to strangers, patients or clients, trying hard to deal with them fairly and conscientiously. Well said.
But this only operates in the short term.
It doesn't mean I can love them all, or at all, or love them equally, or anything like that. That would be meaningless. We don't know what love is exactly, but it does seem to include a sustained form of attention. It provides a space in which the other person can grow.
Such attention is always specific, by its nature; it latches onto a subject, something recognised yet new in the other. It can't be served out like soup. Yet increasingly businesses, bureaucracies and government pretend that it can!
There was a story on HN a while ago that I can't seem to remember the title of.
It was something along the lines of "The optimal amount of slack in an organization is not zero", or something like that.
The argument was that, since it's impossible to plan for every eventuality, you need a certain amount of slack capacity in order to retain some flexibility.
And that by always using 100% capacity, we end up dysfunctional.
I think the same is true for our personal lives.
But the endless treadmill of self-optimization, side-hustles and ever more commitments leaves us unable to cope.
I think it referred to the classic efficiency vs latency tradeoff. Like when emergency vehicles are always on standby, which is inefficient, but allows them to roll out without delay. Conversely privatised rail lines squeeze out every ounce of capacity from the infrastructure resulting in delays when something, anything goes even slightly wrong.
I use this extensively when planning activities with my children. It's a fun challenge because they're both too young to tell the time, much less read, which are constraints one does not normally encounter in their work life.
It was the same problem for JIT supply chains falling apart during COVID.
It's very hard to sell slack to management and so in "well run organizations" it ends up trending towards zero. And then everyone is surprised at the resulting catastrophes.
I can't help you with the title, but with another paragraph from that story, should you want to find it.
Paraphrasing from memory:
> When you are in a major Chinese city you may street sweepers sitting on the side walk chitchatting. The first thing you may think of it as waste that could be eliminated. But it also acts as a buffer.
hey, I hear you. Modern America is full of voices demanding you give them care/attention.
Every.
Single.
Thing.
It is overwhelming. See following comments on the need for slack/margin in capacity. Well, we also need it in emotional demands. Yet every commercially-moderated interaction in our society seems to be optimizing for making us care more about it, because that increases their revenue.
This is why I recently fell in love with libraries. It is one of the few places where ads/manipulation to part you from your money is extremely limited and the demands are so chill.
"Want to borrow a book? Ok."
"Don't want to? Ok. Whatevs."
And even analysis paralysis is overcome with: "Why not both! Borrow two whole books!"
I really resent how our collective attention has been so commoditized. Advertising lies at the core of so many of our problems, and I'm not sure how we can come back.
This is ultimately a dichotomy between having the family unit or "the state" as the central point of governance. Many totalitarian regimes looked at newborns as "belonging to the state". The result is a unified mass person who dresses, thinks and acts in predictable ways.
The more power, personal connection and influence parents have over their children, the more diverse society will become.
> Have you ever been there and met the uniform mass persons?
I was born in Eastern Europe in a society headed in this direction. I observed its transformation after the fall of the Berlin Wall.
You felt the overarching power of the state from as early as the kindergarten. Signs of individuality were suppressed and all children were supposed to do things "the right way". When such an institution decided that a child "systematically misbehaves", it was able to take the child away from its parents in another orphanage-like institution that was supposed to teach them good socialist manners. Eventually some of them would end up seriously harassed, physically-ill and sent to an anonymous grave in the backyard of that institution.
"Care" doesn't scale. You can't just replace "the family" with some industrialized system of raising children and get the same results. Not being able to scale "care" and make it more efficient is almost tautological, really.
> Besides, what countries are you talking about?
North Korea? Former Soviet Union?
At the very least appearance of conformity was ruthlessly enforced and even private conversations were infiltrated to detect dissent.
Totalitarian regimes often uphold traditional values like family as a means of control, promoting unity and loyalty to the state-yet they’ll redefine these values whenever it suits their ideology.
That's not really true. Marxism-Leninism famously sought to abolish the family and the Soviet union performed quite a few experiments in communal rearing of children in it's early years.
The reason why totalitarian regimes end up promoting traditional values relations is that to them the only imperative superior to ideology is survival.
There is a reason the Soviet Union backed off from it's repression of religion in the middle of WW2.
You’re describing the extremes on a spectrum, but you only go to one of the extremes, which exposes your bias.
And it’s a false dichotomy to begin with, since shifting more care work towards society doesn’t equate to a path toward totalitarianism. You’re conflating socialism with totalitarianism. Understandable, but misguided.
Frankly, your whole premise is based on a capitalist narrative that keeps workers in their place because individual care work is so inefficient—it drains energy that could otherwise be channeled into organizing worker councils to balance out the power now disproportionately held by banks, IT corporations, political parties, and the military-industrial complex.
I’m aware that I may come across as an arrogant prick in this comment. I wish I had more time to craft a friendlier response with more sources and explanation, but I simply don’t. I need to work to feed my children and their mother, but anyway, here’s a reading list for anyone who’s interested:
"Capitalist Realism: Is There No Alternative?" by Mark Fisher - Fisher discusses how capitalism has permeated every aspect of life, including care work, and critiques the idea that alternatives like socialism lead to totalitarianism.
"Workers of the World: Essays Toward a New History of the Working Class" by Philip A. H. G. D. Van der Linden - This collection explores the historical context of labor movements and the importance of organizing against disproportionate power structures.
"The Care Crisis: What’s Wrong with Care and How to Fix It" by the Institute of Public Policy Research - This report outlines the societal implications of care work and its impact on worker organization.
"Wages for Housework" by Silvia Federici - Federici argues for the recognition and compensation of domestic labor, linking it to broader struggles against capitalist exploitation.
The whole point is scaling "care work" is almost oxymoronic. Care is only quality care when there are a small number of carers per those being cared for. To make it "efficient" is to turn children, the addicted, the disabled, and the elderly into cattle.
> "Wages for Housework" by Silvia Federici - Federici argues for the recognition and compensation of domestic labor, linking it to broader struggles against capitalist exploitation.
This reveals one of the poorly hid secrets of progressive ideology. Progressives LOVE Capitalism and want to spread it to encompass every human interaction. Caring for your own home, your own children, anything someone might do for a friend or a loved one MUST be turned into a financial transaction with an explicit contract.
Whats much more important, empathy doesn't scale. Care can be established. But no one will ever know about its quality. I know what I am talking about, I visited a k12 school for the blind, and have a mentally unstable mother. Nobody ever asked me if I am happy/content at home. They all assumed my mother is doing her best. My life only started when I managed to escape from every kind of care. Institutionalized care is the worst, because its lacking empathy the most...
> you could probably ... subtract a social worker, as a cost-saving measure.
Anyone who has scheduled 24x7 work knows that you need 4+ people:
24 hrs * 7 days/wk = 168 hrs/wk
So that's 4 shifts of 42 hours each. Caregiving is difficult, very draining work, so 3 shifts of 56 hours isn't going to work (even if that's feasible for any job), and especially over the long term. Then people get sick, take vacations, have family emergencies, etc., so you need additional people available too.
Readit News
So when the author says care "doesn't scale", they obviously mean "you need a one-to-one ratio of caretakers", which I fully agree with. But what they're also accidentally doing in the process is explaining why creating bigger teams with bigger hierarchies and structures does not appear to increase the efficiency of care.
Some projects do need big teams with hierarchies - even in healthcare. Effectively responding to a pandemic comes to mind. I suspect it's when the core problem to tackle most naturally breaks down like a tree - a hierarchy then mirrors the way the problem breaks down. For some projects, like general homecare, the efficiency sweet spot is a flat structure of autonomous individual teams, because it doesn't scale beyond those teams anyway.
And just like the author concludes, I find that there's something comforting about that.
[0] https://en.wikipedia.org/wiki/Buurtzorg_Nederland
[1] https://www.youtube.com/watch?v=SSoWtXvqsgg
Couldn't it be said that when organization acquire ranks, it is to solve coordination problems that arise with scale but that in this case, there isn't much that is solved by more organization ?
The incentives of an organization - or at least of a corporation - are to make money and to continue to exist and to enrich and empower the people who control it. But employees' incentives are usually pretty different. Nurses usually get into nursing because they, at least to some extent, want to help people. Engineers get into engineering because they, at least to some extent, want to build something really good. Teachers get into teaching because they want kids to learn. And so on.
If you're the principal of a school, and your goal is for a teacher to teach, you don't have a coordination problem. Most teachers want to do that. But if your goal is for teachers to maximize standardized test scores, or to minimize the number of frustrated parent calls, etc, you do have a coordination problem, because your goals are misaligned with your employees'.
If you're the CEO of a tech company, and your goal is for your engineers to build good software, you don't have a coordination problem. Your engineers want to do that. But if your goal is to maximize conversions, or to ship faster, or to raise money, etc., you do have a coordination problem.
If you run a hospital, and your goal is for your nurses to care for patients, you don't have a coordination problem. But if your goal is to maximize profits, then you do.
It's usually these kinds of coordination problems that managers are, effectively, in charge of enforcing. Their job is not to help individual employees achieve individual employees' collective goals, it's to make employees feel (sometimes truthfully) like their goals are aligned with the organizational goals, or to use the threat of loss of income or work to force them into line.
Compare that to the pandemic response example I gave: that is the kind of challenge where there are concrete problems at individual, city-wide, national and international scale to tackle, and they're all interconnected too. So plenty of those coordination problems you mentioned.
>trusting them to make the right decisions.
I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?
My mom is a (retired) preschool teacher. By the end of her career, she was working for a school affiliated with a large chain, and maybe 1/3 of her time was spent on filling out all the paperwork required by management. That was time she absolutely was not spending with the kids.
My dad is a (retired) doctor. Similar story there. His hospital ultimately ended up associated with a regional health care network, and the paperwork load ultimately got so bad that they ended up having to hire additional staff dedicated to help the actual health care providers fill out all the paperwork so that they could spend more time actually providing health care.
I switched primary care providers over this a few years back. I had a great doctor, but her practice got bought up by one organization, which then got bought up by another, and over time working with her office became a huge bureaucratic quagmire. I switched to a different clinic that's still local (although also chain with multiple locations), and everything's easier again.
The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work.
tl;dr: It's communication that doesn't scale.
First, note any organization that breaks into different departments (hierarchical or not), at least partially does so to let each department "abstract" away the other ones - if you don't have to worry about issues outside of your responsibility, you can focus more on yours. That is actually a form of trust.
In the case of a hierarchy however, that means that each layer abstracts away the layers above and below, and since going up multiple levels in the hierarchy happens indirectly, the further away, the more abstract things become. So that often needs some kind of structure to regain the trust that is lost by dealing with abstract departments - leading to bureaucracy.
On top of that, usually more power resides higher up the hierarchy. That means that without explicit structures to compensate for this, people lower in the hierarchy lack individual leverage to protect themselves against bad decisions made higher up, that may not even be malicious or intentional but just a consequence of the aforementioned abstraction.
Of course, most structures that are created to fix this typically are also abstract procedures, meaning they barely help with our instinctual "I cannot attach a face to this" type of distrust. Bureaucracy can create leverage, but rarely creates trust. Which also explains that quite often, talking to someone in person can make such a difference in being allowed to "go ahead" or not. Because it can provide a more "natural" sense of trust that bureaucracy is supposed to provide but barely does.
Legally an organisation is usually exposed in relation to its scale, even if the misconduct was limited to one employee trusted to carry out work independently, the penalty will likely be related to the total size of the company.
The second is if you're scale is large enough that you are considering a significant portion of the employees with some skill in a region, you have a harder time selecting for anything other than "holds a qualification" during hiring. This leads to all sorts of policy to prevent someone with qualifications but less integrity causing issues.
A trust-breaking event occurs, so a new form gets added, a compliance process is created with a new team monitoring, etc. etc. Have enough of those and you eventually get your typical, modern healthcare bureaucracy today.
For example you have leading doctors who prefer not to look at patients, even tho they belong to them (from a specialization point of view), as they are "cumbersome" cases. That often leads to them "ignoring" it for some time until someone else takes over, or completely delegating it to non-fit persons.
It's a huge pain for me to heard this every day, because it literally sucks out any desire to work as a doctor from my girlfriend. At the same time, it's infuriating: we pay a lot each year, and with every year more, for services like this. If I was to ever win lottery, I'd use that money to make my own hospital without all of this crap.
Because Buurtzorg has been shown to have lower costs and higher job satisfaction than its competitors, and the reasons are quite obvious too: the hierarchical outsourcing solution adds extra communiciation costs, administration costs, and similar organizational overhead. On top of that patients are in a situation where they see many different unfamiliar care workers briefly, meaning they do not get to form a bond of trust with any one of them. That is a pretty heavy costs that I don't even know how to categorize.
I'd like to offer some comfort to the author on this score. Food, housing, healthcare broadly... while these are all aspects of being "cared for" by society, they aren't all care in the individual sense you describe. The food system is different from homecooked meals; the housing economy is different from the handsome breakfast nook your family DIYed into their home. We can build systems which scale and make it possible and economical for individual care to happen.
This is a good point, and everything I've heard from parents says that it's parents, not children, who identify home-cooked meals with care. Children notoriously prefer prepackaged industrially processed food over whole foods prepared with care and love. In order to feel cared for, all children need is to trust that the person caring for them will make sure they get enough food when they need it. Food quality has nutritional consequences down the line, and at some point a child that is fed pancakes every day will gain the ability to look back and regret how they were raised, but it doesn't prevent a child from feeling cared for in the moment.
Nearly all people do, food scientists are really damn good at their job.
It isn't even that the stuff tastes better, it just triggers more of the pleasure centers in the brain and causes people to want more.
No one eats an entire bag of doritos because they taste better than a good steak.
Don't underestimate the human desire to provide value to the tribe, it runs deep in the evolutionary make-up.
In most cases, this is probably due to the care givers training their children to prefer that kind of food because they don't make many home cooked meals.
I don't even know if it's true, though. When I was a kid, the best food in the world were the home made meals my grandmother made, especially on the holidays. Remember as a teenager telling my Grandma her meals were better than any restaurant I had ever eaten at, and meaning it in all sincerity.
Let me fix that for you:
Children notoriously prefer heavily marketed food in attractive packaging which is designed/optimized for addictiveness and immediate gratification.
I regret nothing. Pancakes are and will always be great.
And even in a "food oasis" with adequate quality, yes, if you yourself cannot prepare a meal, or have nobody to do that for you, that's a failure of a different kind.
https://en.wikipedia.org/wiki/Food_desert
Especially when you look at construction quality, the average quality of say new built condos in any major city has gone way way down since the 90s.
Of course on average condo designs have on average gotten fancier with quirkier architecture, and building codes have gotten more complex, so maybe it’s not due to builders caring way less, but the end result is shoddy work either way.
Edit: And the average home buyer has no method of separating out all these confounding factors, so it boils down to a single congealed mess.
1) I think part of it is due to our ability to fine-tune the limits. Before, if a company wanted to pass an inspection, they had to be really confident. There were going to be some expenses that in theory they could have avoided if they were better capable of measuring where the line between 'safe' and 'unsafe' was. The end result was buildings that were more safe than strictly required. But now we can get closer to the line, and so buildings are engineered at the edge of safety.
2) Of course, survival bias plays a role here. Who remembers all the crappy buildings that just vanished? It's the same reason we look at old toasters or mixers or what-have-you and say things were so much better-made in the past - all the crappy cheap toasters, mixers, and houses are gone now.
3) Also, as extreme weather has happened more frequently, areas all over are seeing weather different than what they were designed for. Given that the average temperature in Oregon in July (the hottest month of the year) was typically around 65 degrees Fahrenheit[1]. For the past few years it has generally hovered in the upper 60s. The hottest temperature ever recorded in Oregon before 2021 was 107 degrees Fahrenheit[2], and typically there were one or two days a year that crossed one hundred degrees -- occasionally five, more often none. In 2021, it hit 116 degrees. Since 2021, there has not yet been a year without 4 or more days over a hundred. And, of course, this pattern is repeated all over the world. Houses are being built for one set of extremes and averages and getting another.
[1] https://www.ncei.noaa.gov/access/monitoring/climate-at-a-gla...
[2] https://projects.oregonlive.com/weather/temps/
More from a recent report by Australia's business council of coops and mutuals: https://bccm.coop/australia-urged-to-look-to-europe-for-solu...
Anyway, my advice to the author was that systems can enable care at scale. Not to say that our current systems do.
Edit: to be more explicit, I'm suggesting that some approaches to the housing sector in some parts of Europe amount to care that scales; society and governments have decided that housing is a right, and have enacted policies to approach that situation. Conversely, a "we don't care" approach also scales very well with the opposite outcome.
Absolutely. Society tends to assume that people are interchangeable units and that 'care' is a commodity which can be dispensed evenly as if from an industrial nozzle in a food factory. So we have 'care homes', 'daycare', 'care packages'. We are enjoined to be more 'caring'.
But the reality is that love, which is what we're really talking about, is dyadic.
i.e. between two individuals. That's how it works and how it effects its magic.
A patchwork of dyadic connections is what we may hope for and build.
The earlier the intervention the better.. and consistency is also incredible important. But you can spend incredible amounts of money just to get a slightly worse outcome than what was going to happen on its own. As a wealthy society we must do something to help those in need, especially children who are in the situation of no fault of their own. But it's not clear our current methods work.
You can also generalize this problem to the healthcare industry as a whole. Costs go up much faster than the rest of the basket of goods & services citizens pay for, and they don't understand why.
The underlying reason is that - care doesn't scale. You are essentially (directly or indirectly) paying for someone's (doctor, nurse, etc) time. We have not gotten much better at making care more time efficient in the field, and in many cases it has gotten worse (more paperwork/electronic record entry time/etc). Everything else we buy is the product of using automation to replace labor, making labor more efficient, or making labor cheaper (offshoring / simplifying so less training is needed / etc).
The evidence very strongly points the other way, IMHO:
Almost all people care deeply and individually about many others, starting with their families - spouse and children are a clear and I think irrefutable example of deep caring and love for multiple people. And for most, also siblings, parents, grandparents, and some or even many other relatives.
And outside of family is friends, co-workers, etc. Many healthcare workers care deeply (depending on the meaning) about their patients. Fundamental human empathy enables us, if we choose, to see people as individuals and care about them, even people we meet briefly on the street. I've learned to do it and I'm not superhuman.
Obviously we know people experience these things. Why is it important - to what ideology and why - to insist empathy and love is so limited.
Yes, I may show empathy and respect to strangers, patients or clients, trying hard to deal with them fairly and conscientiously. Well said.
But this only operates in the short term.
It doesn't mean I can love them all, or at all, or love them equally, or anything like that. That would be meaningless. We don't know what love is exactly, but it does seem to include a sustained form of attention. It provides a space in which the other person can grow.
Such attention is always specific, by its nature; it latches onto a subject, something recognised yet new in the other. It can't be served out like soup. Yet increasingly businesses, bureaucracies and government pretend that it can!
Dead Comment
My experience (and I believe it to be common) is that I'm really, really, really out of spare energy to care about anyone or anything else.
Mind you, I'm in my best shape in years and I've explored my limits to find out they're actually way further than I originally thought, but still.
It was something along the lines of "The optimal amount of slack in an organization is not zero", or something like that.
The argument was that, since it's impossible to plan for every eventuality, you need a certain amount of slack capacity in order to retain some flexibility. And that by always using 100% capacity, we end up dysfunctional.
I think the same is true for our personal lives.
But the endless treadmill of self-optimization, side-hustles and ever more commitments leaves us unable to cope.
I use this extensively when planning activities with my children. It's a fun challenge because they're both too young to tell the time, much less read, which are constraints one does not normally encounter in their work life.
It's very hard to sell slack to management and so in "well run organizations" it ends up trending towards zero. And then everyone is surprised at the resulting catastrophes.
https://www.neelnanda.io/blog/38-slack
> When you are in a major Chinese city you may street sweepers sitting on the side walk chitchatting. The first thing you may think of it as waste that could be eliminated. But it also acts as a buffer.
TL;DR: Pretty much what you said, but he labeled it "margin" instead of "slack". But yeah, you need some.
Every.
Single.
Thing.
It is overwhelming. See following comments on the need for slack/margin in capacity. Well, we also need it in emotional demands. Yet every commercially-moderated interaction in our society seems to be optimizing for making us care more about it, because that increases their revenue.
"Want to borrow a book? Ok." "Don't want to? Ok. Whatevs."
And even analysis paralysis is overcome with: "Why not both! Borrow two whole books!"
Care could scale, but we’d need the culture and societal changes to allow it to scale.
The more power, personal connection and influence parents have over their children, the more diverse society will become.
Besides, what countries are you talking about? Have you ever been there and met the uniform mass persons?
I was born in Eastern Europe in a society headed in this direction. I observed its transformation after the fall of the Berlin Wall.
You felt the overarching power of the state from as early as the kindergarten. Signs of individuality were suppressed and all children were supposed to do things "the right way". When such an institution decided that a child "systematically misbehaves", it was able to take the child away from its parents in another orphanage-like institution that was supposed to teach them good socialist manners. Eventually some of them would end up seriously harassed, physically-ill and sent to an anonymous grave in the backyard of that institution.
"Care" doesn't scale. You can't just replace "the family" with some industrialized system of raising children and get the same results. Not being able to scale "care" and make it more efficient is almost tautological, really.
> Besides, what countries are you talking about?
North Korea? Former Soviet Union?
At the very least appearance of conformity was ruthlessly enforced and even private conversations were infiltrated to detect dissent.
The reason why totalitarian regimes end up promoting traditional values relations is that to them the only imperative superior to ideology is survival.
There is a reason the Soviet Union backed off from it's repression of religion in the middle of WW2.
Like in the Democratic, liberal West, where everyone's individuality is created by consuming the same stuff?
And it’s a false dichotomy to begin with, since shifting more care work towards society doesn’t equate to a path toward totalitarianism. You’re conflating socialism with totalitarianism. Understandable, but misguided.
Frankly, your whole premise is based on a capitalist narrative that keeps workers in their place because individual care work is so inefficient—it drains energy that could otherwise be channeled into organizing worker councils to balance out the power now disproportionately held by banks, IT corporations, political parties, and the military-industrial complex.
I’m aware that I may come across as an arrogant prick in this comment. I wish I had more time to craft a friendlier response with more sources and explanation, but I simply don’t. I need to work to feed my children and their mother, but anyway, here’s a reading list for anyone who’s interested:
"Capitalist Realism: Is There No Alternative?" by Mark Fisher - Fisher discusses how capitalism has permeated every aspect of life, including care work, and critiques the idea that alternatives like socialism lead to totalitarianism.
"Workers of the World: Essays Toward a New History of the Working Class" by Philip A. H. G. D. Van der Linden - This collection explores the historical context of labor movements and the importance of organizing against disproportionate power structures.
"The Care Crisis: What’s Wrong with Care and How to Fix It" by the Institute of Public Policy Research - This report outlines the societal implications of care work and its impact on worker organization.
"Wages for Housework" by Silvia Federici - Federici argues for the recognition and compensation of domestic labor, linking it to broader struggles against capitalist exploitation.
There are plenty of reasons to believe that yes, it does. This is something that is almost completely unknown (except on the extremes).
And history has those two coupled in very complex, hard to understand ways.
The whole point is scaling "care work" is almost oxymoronic. Care is only quality care when there are a small number of carers per those being cared for. To make it "efficient" is to turn children, the addicted, the disabled, and the elderly into cattle.
> "Wages for Housework" by Silvia Federici - Federici argues for the recognition and compensation of domestic labor, linking it to broader struggles against capitalist exploitation.
This reveals one of the poorly hid secrets of progressive ideology. Progressives LOVE Capitalism and want to spread it to encompass every human interaction. Caring for your own home, your own children, anything someone might do for a friend or a loved one MUST be turned into a financial transaction with an explicit contract.
Most of care will not be automated any time soon. And it is a huge part of the economy.
Nice to see this post on HN.
Anyone who has scheduled 24x7 work knows that you need 4+ people:
So that's 4 shifts of 42 hours each. Caregiving is difficult, very draining work, so 3 shifts of 56 hours isn't going to work (even if that's feasible for any job), and especially over the long term. Then people get sick, take vacations, have family emergencies, etc., so you need additional people available too.