464 ILR Review

that allows the capitalist pig to successfully follow its life cycle all the way to the disassembly
line.
At one level, this finding echoes calls for solidarity made by animal rights activists who poi-
gnantly observe that the conditions we subject industrial animals to are also the conditions
under which industrial farm workers labor. By working inside the farm, Blanchette is able to
witness what that solidarity looks like in action as he describes the moments of intimacy his
co-workers establish with pigs they are otherwise told to treat as company property. “Somos
puercos” (“we are pigs”), one of Blanchette’s Latin American co-workers declares, which is an
expression that self-reflexively situates farmworkers such as herself and pigs within a racial
capitalist order generated by the industrial farm. The sentiment also gestures toward an
expansive sense of labor solidarity between the humans and the industrial pigs.
What is refreshing about Porkopolis is its refusal to narrate this story as a simple matter
of good and evil. The thoroughness with which this study is conducted reveals details that
defy simplistic normative judgment. In the book’s background, the pork industry’s concerted
efforts to shield itself from regulation and union accountability through political and legal
maneuvering are mentioned. From environmental degradation, to monopolized markets, to
worker exploitation, the harmful leakages produced by this system of production are cited
throughout the text. Those ugly truths, however, are situated next to other truths such as
an insatiable global appetite for cheap pork, rural towns desperate for investment and jobs,
and workers who have made lives and careers for themselves in industrial pig farming. Such
details are not included to complicate the question of whether industrial pig farming is worth
doing. Blanchette is emphatic that it is not. Instead, they evince the numerous entanglements
that keep this system going even as those charged with its management and maintenance
question its sustainability.
Porkopolis ultimately leaves its reader to ask, what would it mean to truly be “post” indus-
trial? While the book never answers this question directly, the many allusions to post-work
politics, and the references to post-work scholars, suggest Blanchette finds inspiration from
those who insist society can no longer equate abundance with conspicuous consumption nor
measure an economy’s health solely in terms of goods produced and services rendered. Yet,
whether a postindustrial agriculture signals a world with less work is not entirely clear, espe-
cially if what characterizes the industrial farm is its intense concentration of pig and human
labor into a relatively smaller space. Perhaps, instead, the postindustrial farm is replaced by
numerous smaller farms with more people overall employed in agriculture. If we set aside
the utopian thinking that often characterizes post-work theorization and sit in the muck left
over after nearly two centuries of industrialization, Porkopolis casts some doubt as to whether
a low-work future is possible, or even desirable. Stated in a slightly different way, what if the
future of work, and its postindustrial possibilities, were framed not as a matter of whether
society will have enough work for people to do but was instead treated as an invitation to ask
what society ought to work for?

Brandon Hunter-Pazzara
Adjunct Professor
Georgetown University
brandon.hunter87@gmail.com

Ethically Challenged: Private Equity Storms US Health Care. By Laura Katz Olson. Baltimore, MD:
Johns Hopkins University Press, 2022. 440 pp. ISBN 9781421442853, $34.95 (hardcover);
ISBN 9781421442860, $34.95 (e-book).

DOI: 10.1177/00197939221110551

Laura Olson’s excellent Ethically Challenged does exactly what one would expect from the title.
It provides an exhaustive sector-by-sector, case-by-case exploration of private equity finance’s
growing and mainly adverse effects on US health care. The book comprises nine substan-
tive chapters and a brief introductory overview and conclusion. Chapter 1 provides a short
account of standard private equity finance (PE) terminology and explanation of the business
 Book Reviews 465

model. Chapter 2 sets out a brief history of PE and how it has adapted to and sought to influ-
ence in turn its regulatory and financing environment. This background is both necessary
and useful because despite the pervasiveness of PE, its “alternative investment management”
practitioners have worked hard to maintain a low public profile, preferring to divert atten-
tion to their individual businesses rather than the common agents that stand behind them.
Practitioners also work hard to influence those who might, from both sides of the aisle, enact
law that affects them. This strategy has avoided widespread “I can’t believe this is legal” senti-
ment while allowing industry representatives to control the narrative.
As Olson makes clear, for those unfamiliar, PE is a practice in which a financial manage-
ment firm solicits a fund of capital, usually for 10 years, from investors (limited partners or
LPs). The management firm provides the general partner (GP) who uses this “equity” in
conjunction with debt (an LBO) to acquire companies or divisions that form a portfolio. A
combination of financial restructuring (“engineering”) and operational restructuring are
applied prior to “exit” from the investment, typically over three to five years. There are two
main perspectives or groups of theory regarding the PE business model. One perspective
places greater emphasis on operational restructuring: PE buys companies in need of owner-
ship transition and growth capital or alternatively buys failing companies and turns them
around. In both cases, the claim is that PE is adding value and realizes a capital gain on sell-
ing a leaner and more efficient company in the future. The other perspective places greater
emphasis on the financial engineering: PE is looking for companies that are vulnerable to
buyout but have some capacity to debt service, since it is the acquisition that is eventually
liable for the debt used in part to buy it, and debt is key to capital restructuring of the acqui-
sition and return on investment to LPs and GPs. In this case, the claim is that debt servicing
dominates all other aspects of strategy, but crucially the main focus is generating returns to
the fund and management firm. The portfolio company is simply a means to this end, and
financial success of the fund is not dependent on improving the acquisition.
The first perspective tends to tell a tale of entrepreneurial wealth creation and the second
of predatory wealth extraction. Olson’s book is very much of the second kind, which is by no
means to suggest it misrepresents its subject. Chapter 3 explains how the PE model has been
applied to US health care, and this chapter provides a template for the range of strategies
applied to each sector in the subsequent chapters. In most sectors, US health care has a frag-
mented ownership structure and a complex administrative burden in terms of compliance
with requirements of insurers and regulation for public and private provision. This circum-
stance in the context of the continual growth of the health care sector and the scope to
exploit dependable income streams represents a profitable opportunity for PE. Instead of
seeking to buy large companies and break them up to sell the parts for more than the origi-
nal value, which has been a standard PE practice, the main strategy in health care has been
consolidation or “buy and build.”
The PE firms look to acquire an initial platform company and then engage in mergers and
acquisitions on the premise that once the company achieves a critical threshold in terms of
scale, the value of the whole when exited is greater than the sum of the acquired smaller enti-
ties. The PE firms often appear as an attractive proposition to prospective sellers insofar as they
offer to take on administrative burdens, in principle freeing health professionals to focus on
patients, with the added incentive of offering lucrative financial inducements to founders and/
or owners, such as premiums on the value of the business. However, following the standard PE
“playbook” acquisition by LBO involves considerable debt. The portfolio company is required
to free up cash flow to service that debt. Moreover, temptation is high for the GP to frontload
repayments to their funds to reduce the risk that funds will not achieve financial targets and to
access carried interest performance fees for GPs. GPs are thus highly motivated to engage in
recapitalizations and refinancing to expedite dividend payments to funds; these activities also
trigger various fees from portfolio companies. Hence, predatory wealth extraction.
The net effect, however, repeated in sector after sector, is greater debt loads, debt distress,
and both a pressure and need for portfolio companies to cut costs. Crucially, cutting costs in
the context of PE strategy is a perverse form of efficiency saving. No commensurate fall occurs
in costs to patients, since all available funds are directed away from the portfolio company
either to service debt or to create returns to LPs and GPs. All too often efficiency and quality
of patient care start to diverge, management comes under financial pressure, and employees
suffer. The consequences are predictable. Either through perverse incentives or desperation,
numerous problematic, and in some cases egregious, practices follow: reduction in staffing
numbers and qualification levels of staff, reduced investment, under-stocking of facilities with
466 ILR Review

life-saving equipment, focus on high-margin treatments even if they are of little clinical value,
neglect of effective low margin or difficult treatments (long-term counseling eschewed in
favor of medications, etc.), unnecessary treatments, increased charges, deliberate overcharg-
ing, negligence, abuse and fraud (directed at insurers as well as Medicare and Medicaid), and,
of course, the most high-profile practice in recent years, “surprise billing,” which exploits out-
of-network insurance criteria.
Each chapter after Chapter 3 is essentially a variation on this general argument and how it
affects general practitioner physicians, dentistry, and specialisms ranging from dermatology to
dialysis facilities, but also how it affects the full range of health care services in which commer-
cial entities have gained a foothold: home care agencies, hospices, rehabilitation centers for
drug and alcohol dependencies and eating disorders, as well as autism spectrum disorder treat-
ment centers, and finally in Chapter 9, ground and air emergency medical transport services.
Olson’s point is simple. PE goes where the money is, and in health care PE is everywhere. More-
over, many of the brakes one might expect—from financing or regulators—are not working, as
PE flies under the radar and controls its narrative. When banks might become reluctant to
lend, or retail investors less keen to support IPOs, PE turns to other PE firms to provide below
investment grade financing and to other PE for secondary buyouts. The direction of travel,
unless action is taken, is all too foreseeable: PE is tending toward local, regional, and poten-
tially national financially precarious monopolies. Not only can the failure of these providers
ultimately deny vital services to communities and the vulnerable, in the meantime providers
lose the sense that such service provision is their purpose—which is a further step down the
track of treating patients as customers and health care as no different in principle from any
other business in a caveat emptor world. It is with this in mind that Olson’s ultimate framing of
her work is ethical. Financialized PE may be problematic in any circumstance, but its hyper
financial incentive structure is particularly at odds with provision of care in all of its forms.
The book then is a timely exposé in the spirit of Eileen Appelbaum and Rose Batt’s Private
Equity at Work and is perhaps best read in conjunction with that. Its greatest strength is also likely
its main weakness. As noted, it has a sector-by-sector and case-by-case approach, and though this
establishes the problem of PE is structural and systematic rather than “a few bad apples,” the
book is somewhat episodic and wearisome to read in long sittings. I would suggest dipping in
and out. More traditional business school academics are likely also to object to its evocative lan-
guage (e.g., devour, insatiable, snatch, clutches, fleecing) and its fragmentary approach to evi-
dence. However, if the practices described in the context of health care do not warrant such
language then nothing does. Moreover, the very need to piece together an argument from frag-
ments gives you some sense of the problem PE represents: an ability to reject transparency and
suppress criticism, which Olson struggled with in putting together data and material from inter-
views, hampered by nondisclosure agreements at every turn. Read in this light she has done a
service to scholars and students. As a final note, I read Ethically Challenged as a citizen of the
United Kingdom, another country where PE has made great inroads, but one where most health
care is still considered a basic human right available free to all at the point of need, albeit this is
under slow and corrosive attack. Looking from the outside, Olson’s book is even more poignant.

Jamie Morgan
Professor
School of Economics, Analytics and International Business
Leeds Beckett University Business School
j.a.morgan@leedsbeckett.ac.uk

Mass Strikes and Social Movements in Brazil and India: Popular Mobilisation in the Long Depression.
By Jörg Nowak. Springer Nature Switzerland AG: Palgrave Macmillan, 2019. 330 pp. ISBN
9783030053741, $109.99 (hardcover); ISBN 9783030731267, $109.99 (paperback).

DOI: 10.1177/00197939221125200

Jörg Nowak’s Mass Strikes and Social Movements in Brazil and India explores new research that
challenges the traditional approach of industrial relations research. His book is based on
Copyright of ILR Review is the property of Sage Publications Inc. and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.