Curiosity of Complexity Killed the Cat?

 

Curiosity of Complexity Killed the Cat?

How Healthcare System Complexity Harms and Heals People 

Complexity did not simply arrive in healthcare; it was curated. Layer upon layer of administration, technology, specialty services, and regulatory processes have transformed a system designed to heal into one that often delays, distorts, and exhausts. The result is a paradox: a system that spends more than ever yet leaves many people without timely access to the care they need most. This essay argues that healthcare complexity has first harmed the system itself and, in doing so, has harmed patients. It further contends that while technological advances hold promise, their current deployment often undermines human care, inflates costs, and diverts resources from primary and public health—the very foundations of population health and economic productivity.

The architecture of complexity: primary, secondary, and tertiary care

Healthcare is commonly described in three levels. Primary care is the first point of contact for individuals and families, focused on prevention, early diagnosis, and ongoing management of common conditions. Public health complements this by addressing community and environmental determinants of health—vaccination programs, health promotion, and policies that shape the social conditions in which people live. Evidence consistently shows that strong primary and public health systems yield better outcomes for most people at lower cost.

Secondary care involves specialist services accessed via referral from primary care—cardiology consultations, appendectomies, diagnostic imaging, and acute hospital care. Tertiary care is highly specialized, complex care for rare or severe conditions, typically delivered in large academic or regional hospitals: organ transplants, neurosurgery, advanced oncology, and complex cardiac procedures.

These distinctions matter because they map onto need. Most people, most of the time, require primary and public health services. Secondary care is necessary for a smaller subset of the population at any given time. Tertiary care, while lifesaving for specific patients, serves a tiny fraction of the population but consumes a disproportionate share of resources. Yet in many jurisdictions, including Ontario, funding and administrative attention flow first to hospitals and specialty programs, even though primary and public health interventions prevent more illness across the life course.

Where the money goes: administration, executives, and the mid-layer

A central driver of complexity is the growth of healthcare administration. In Ontario, the annual Sunshine List reveals the scale of executive compensation in publicly funded institutions. In 2025, the top hospital CEO earned nearly $940,000, with several others above $700,000; the average hospital CEO salary was over $350,000—nearly three times the average hospital-sector salary. At Ontario Health, the provincial agency overseeing system coordination, the CEO’s total compensation exceeded $830,000, while the agency employed over 1,500 staff with an average salary around $129,000. Some association and agency executives earn double what many hospital CEOs make, raising questions about how these roles are valued relative to frontline impact.

This “mid-layer” of managers, consultants, and administrators is not inherently bad; coordination and policy work are necessary. But when this layer expands without clear accountability for frontline implementation, it becomes a sink for public funds. Policies are written, committees meet, and reports are published, yet there is rarely mandatory evaluation of whether these initiatives change practice at the bedside or in clinics. The result is a system that appears busy but moves slowly where it matters most: access to timely, human-centered care.

Technology’s double edge: promise, dependency, and workaround culture

Technology in healthcare was supposed to simplify. Electronic medical records (EMRs), decision support tools, telehealth platforms, and now artificial intelligence were marketed as solutions to fragmentation, error, and inefficiency. Yet after my two decades in health informatics, many frontline clinicians report the opposite: more clicks, more alerts, more time spent documenting than caring. Nurses and physicians rarely say, “I love this tech solution.” Instead, they adapt—building workarounds to keep patients moving through the system.

Workarounds are often stigmatized as deviations from evidence-based practice, yet they are essential survival strategies in a complex system. They allow staff to bypass clunky EMR workflows, expedite wound care, or ensure documentation is completed despite poor interface design. These adaptations are not acts of rebellion; they are acts of care. However, because they occur outside formal protocols, they are invisible to quality metrics and research. No one measures how many hours of nursing time are saved by a workaround, or how many patients benefit from a process that bends the rules to prioritize healing.

The cost of this complexity is not only human; it is economic. Health technology vendors—EMR companies, device manufacturers, and now AI firms—extract significant public funds with limited scrutiny. Interoperability across provinces and facilities remains poor, and outcome-based research on the benefits of these systems during routine operations or pandemics is sparse. Meanwhile, the promise of AI looms large, with companies positioning themselves as saviors of an overburdened system. Yet without addressing the root causes of complexity—fragmented workflows, administrative bloat, and misaligned incentives—AI risks automating inefficiency rather than eliminating it.

The economic case for simplicity: health as a driver of growth

The argument for rebalancing toward primary and public health is not only moral; it is economic. Research by Bloom and Canning demonstrates that health is a core input to economic growth, not merely a humanitarian concern (see Well, 2007 and Harvard article link below). Improvements in adult survival, vaccination coverage, and maternal health raise productivity in measurable ways, with effects comparable to traditional drivers like education or infrastructure. Their work reconciles microeconomic and macroeconomic evidence, showing that health interventions yield returns that justify prioritization in national budgets.

If health drives growth, then a system that delays access to primary care undermines its own economic foundation. When people wait weeks or months for appointments, when chronic conditions go unmanaged, and when preventive services are underfunded, productivity suffers. Absenteeism rises, disability claims increase, and the burden on acute and tertiary care grows—precisely the expensive end of the system that consumes disproportionate resources.

In Canada, where healthcare is publicly funded through taxation, this misallocation is particularly striking. Taxpayers contribute significant portions of their income to a system that, by design, should prioritize population health. Yet access to same-day or even same-week primary care appointments has become rare in many regions. People host illnesses for days, years, or decades without treatment—not because of staff shortages, but because the system’s complexity creates bottlenecks.

A personal lens: from frontline to policy and back again

Having worked across the spectrum—from public health nursing to clinical policy and practice consulting, to health informatics—I have seen how complexity erodes both care and caregiver. Early in my career, I followed manuals and medical directives faithfully, only to witness leaders grant special treatment that bypassed the same rules. Later, in policy roles, I was overwhelmed by the volume of research and directives on my desk, wondering how many would ever reach the frontline. The implementation lag is not a bug; it is a feature of a system that rewards activity over impact.

I have also been harmed by regulatory processes—both through my own missteps and through reports by others. These experiences left scars on my professional identity and reinforced a troubling truth: the system punishes deviation even when that deviation serves patients. Workarounds get people back on their feet, yet no one formally acknowledges their value. Instead, staff are expected to twist themselves into pretzels to fit the system, rather than the system being redesigned to fit human needs.

This tension is personal. As a refugee and immigrant to Canada, I cherished the opportunity to study nursing and kinesiology as undergraduate degrees here, and to pursue a master’s in international public health in Australia. I entered healthcare hoping to help people at the frontline and in policy. Instead, I lost my path—along with many colleagues who share this disillusionment. The system does not need this much complexity, and tech giants do not need this much leverage.

Reimagining care: human-to-human, cradle to grave

What would a simpler, more humane system look like? It would prioritize access to primary and public health services across the life course, from cradle to grave. It would offer a no-screen option for those who want to speak to a person rather than navigate a portal. It would hire more frontline staff and deflate the mid-layer administration that consumes public funds without clear frontline impact.

Technology would still play a role, but it would be subordinate to human care. EMRs would be designed with clinicians, not just administrators, in mind. AI would augment—not replace—clinical judgment, and its deployment would be tied to outcome-based evaluations. Interoperability would be mandatory, not optional, ensuring that patient information flows seamlessly across provinces and facilities.

Most importantly, the system would acknowledge the value of workarounds—not as deviations, but as signals of design failure. When staff consistently bend rules to get work done, it is not a sign of noncompliance; it is a sign that the system is broken. Listening to these signals, and redesigning workflows accordingly, would be a first step toward simplicity.

Conclusion: curiosity, complexity, and the cat

The title of this essay borrows from the proverb “curiosity killed the cat,” but with a twist: it is not curiosity itself that is dangerous, but the curiosity of complexity—the belief that more layers, more technology, and more specialization will solve problems that often require less. Healthcare used to be simpler. A doctor or nurse listened, examined, and acted. Referrals were made when needed, and surgery was scheduled when pain or limitation demanded it.

Today, in 2026, getting an appointment can feel impossible. Humans can host illness for years without treatment, not because we lack trained staff or tax revenue, but because the system’s complexity creates barriers. The mid-layer of administration absorbs funds, executives earn salaries that dwarf those of frontline workers, and tech vendors extract public dollars with limited accountability. Meanwhile, primary and public health—the foundations of population health and economic growth—remain underfunded.

The path forward requires courage: to admit that workarounds are essential, to measure what matters (access, outcomes, human experience), and to rebalance funding toward prevention and primary care. It requires skepticism toward the next technological promise, especially AI, until it proves it can enhance—not replace—human connection. And it requires a commitment to a system that serves people, not processes.

By 2030, the goal should be clear: more access to primary and public health services, fewer preventable illnesses, and a frontline workforce that is supported, not stifled, by the system around them.

Screens should not replace humans; they should enable them.

And the mid-layer should shrink, not grow, as public funds are redirected to where they do the most good: keeping people healthy, together, across the life course.

 

About the Author

Renata was born in 1984 in Oradea, Romania, a region marked by Hungarian legacies and Romanian cultural tensions since the 1920s (Treaty of Trianon), as she became a refugee at age four when her family fled the communist regime in 1988. She grew up in post-communist Budapest, Hungary (schooling) and Oradea, Romania (summer vacations), experiences that shaped her social justice and ethical compass, and led her to challenge oppressive and racist health and social service systems throughout her nursing career. Her father and brother spend fiver years (1990-95) in Rochester, New York in hopes for her mother and herself to follow but at that time families could not easily join. Her family immigrated to Guelph, Ontario, Canada in 1996 and has called this lovely and safe place home even across her decades of travel and nursing career. Since completing nursing school in Canada (2003–2008) and continuing through diverse roles in ortho-trauma, med-surg, rehabilitation, mental health, long-term care, public health, outbreak management, policy consulting, education, and global humanitarian work (2009–2019), she has consistently challenged the status quo, even when it meant alienating friends, colleagues, and family.

Today, she firmly believes nursing and healthcare remains the most human-centered profession, uniquely positioned to challenge profiteering practices, build regulatory and safety guardrails through healthy public policy, and resist automation of human-care work. Grateful to other nursing and public health authors for helping her articulate the political nature of her own choices, she writes in hopes that reflection, awareness, and philosophy will offer others the same healing she has found through two decades of authentic practice in nursing and across the health system.

 

References

Butler, Michael. “$8 Billion down the Drain in Ontario P3s.” The Council of Canadians, December 10, 2014. https://canadians.org/analysis/8-billion-down-drain-ontario-p3s/.

Canada, Health. “About Canada’s Health Care System.” Education and awareness. August 22, 2016. https://www.canada.ca/en/health-canada/services/canada-health-care-system.html.

Canadian Museum of Health Care. “The Story of Tommy Douglas and Hospital Insurance.” Accessed September 4, 2026. https://www.museumofhealthcare.ca/blog/the-story-of-tommy-douglas-and-hospital-insurance.

John Ralston Saul. On Equilibrium. 2001. https://www.amazon.ca/Equilibrium-John-Ralston-Saul/dp/0140288031.

Nason Maani, Mark Petticrew, and Sandro Galea. The Commercial Determinants of Health. Oxford University Press, 2022. https://academic.oup.com/book/44473.

Noral Loreto. Corporate Control. 2025. https://www.dundurn.com/books_/t22117/a9781459753136-corporate-control.

“Ontario Sunshine List | Search for People, Employers, Positions.” Accessed September 4, 2026. https://www.ontariosunshinelist.com/.

“Petition E-7691 - Petitions.” Accessed September 4, 2026. https://www.ourcommons.ca/petitions/en/Petition/Details?Petition=e-7691.

Robert Chapman. Empire of Normality. 2023. https://www.plutobooks.com/product/empire-of-normality/.

“The Bungled History of One Government IT Project, Called Panorama | Vancouver Sun.” Accessed September 4, 2026. https://vancouversun.com/news/metro/the-bungled-history-of-one-government-it-project-called-panorama.

“Understanding the Link Between Health and Economic Growth: CID Faculty Research Insights.” June 12, 2025. https://www.hks.harvard.edu/centers/cid/voices/understanding-link-between-health-and-economic-growth-cid-faculty-research.

Well, David N. “Accounting for the Effect Of Health on Economic Growth.” The Quarterly Journal of Economics 122, no. 3 (2007): 1265–306. https://doi.org/10.1162/qjec.122.3.1265.

“Who Started Canada’s Universal Health Care System? | CMA.” Accessed September 4, 2026. https://www.cma.ca/healthcare-for-real/who-started-canadas-universal-health-care-system.

“Universal Health Coverage.” Accessed September 4, 2026. https://www.who.int/health-topics/universal-health-coverage.

 

 

A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation (green paper)

As it appears on the NurseManifest blog: https://nursemanifest.com/2026/08/31/a-nursing-manifesto-for-2030-human-care-against-extraction-and-exploitation-green-paper/ 

Aug 22, 2026

Please use this document in any way that you wish. You can freely use this document (with citation; see our creative commons license in the footer of this and all pages on this site)  The format for citing the document is shown at the end of the table of contents. If you wish to have other ideas integrated into this document, or included on this web site, please contact us or the author directly renata@adaptablefolks.com

1.     Introduction
2.     Planetary Health is Nursing Work
3.     Commercial Determinants of Harms and Health: Get Political  
4.     Nursing Is Not a Buffer for System Failure
5.     Against the Medical-Industrial Complex
6.     Our Commitment
7.     A Call to Conscience and Action
8.     About the Author
9.     Reference list (see image)

Citation: Mares, R. E. (2026). A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation (green paper). https://nursemanifest.com/2026/08/31/a-nursing-manifesto-for-2030-human-care-against-extraction-and-exploitation-green-paper/

Foreword

I came across this incredible blog post about A Nursing Manifesto 2000 written by three incredible nurses and academics: Richard Cowling, Peggy Chinn, Sue Hagedorn in 2000 and I thought to develop a parallel manifesto which brings together some of the books I have been reading over the past 5 years post-pandemic and some which reaches further back to the 80s 90s, 2000s, till present time.

The world have shifted quite a bit since this manifesto was developed and shared. In and of itself, it reads like something to aspire to. Maybe when I started my nursing career as a new graduate back in 2008, it would have been something to aspire to in my own work, career, research and teaching. But now I find some pretty troubling things not only missing from this manifesto as historical accounts, including the troublesome origins of the nursing and medical profession / culture, but it needs to be updated for the year 2030 and beyond.

But first, take some time to read and get familiar with A Nursing Manifesto 2000: https://nursemanifest.com/a-nursing-manifesto-a-call-to-conscience-and-action/

Below is the introduction to A Nursing Manifesto: A Call to Conscience and Action written in 2000. I am sharing here just the initial Introduction, but please do have a read of the entire manifesto as it discusses the ideals and principles, inspiration, concerns, vision and suggestions for actions. It also describes the authors and their positionality and about the art contained within this blog.

A Nursing Manifesto: A Call to Conscience and Action (2000)

by Richard Cowling, Peggy Chinn, Sue Hagedorn

Introduction (excerpt)

“As nurses, we reach for meaningful expressions of our values, too often finding overwhelming constraint and resistance, sometimes within ourselves and sometimes imposed from without. We are calling for a movement to awaken those precious and powerful ideals that are rooted in nursing’s worldwide historical traditions. We call forth the written and spoken voice of nursing to be claimed and reclaimed. We seek to inspire the fullest expression of the heart of nursing through individual and collective acts. We believe there are profound possibilities in claiming our individual and professional sovereignty” … link to full manifesto here: https://nursemanifest.com/a-nursing-manifesto-a-call-to-conscience-and-action/#intro

My initial thoughts on this this first paragraph would be:

• Awakening the so called ‘precious and powerful ideals’ is definitely a good thing, but how does nursing as a profession and value-based career wrestle with the monolith it has created the lack of diversity over the course of centuries
• Rooted in nursing’s worldwide historical traditions: would these discuss how Nightingale-like nursing is rooted in supporting war and military efforts? Would these traditions address the issues of explicitly racism, sexism, and harmful medical cultural administrative practice over the course of the centuries? Our current professional associations are build as empires where lack of diverse leadership opportunities persist and patriarchal hierarchies are celebrated as excellence.
• Attrition in nursing and healthcare is at crisis levels, yet no one talks explicitly about trauma and cPTSD experienced not from patients, toxic teams, but administrative and regulatory practices. Anyone care to elaborate here?

As I was reading this incredible manifesto and remembering back to the year 2000, I started to draw both parallels and the need to advance these exact thoughts to the years 2030 and beyond. At first I had the idea of taking each section and paragraph and write my thoughts in support and opposition. But then I thought, why not take all that I have read and know and develop something totally new yet complementary. Building upon my elders’ work.

Believe it or not, I have a fear of writing my own voice and ideas down. I don’t want to hurt feelings and I do get intimidated by folks who are much more qualified than myself, and therefore, I have the feeling that maybe I should not share what I have to say. I am now slowly building back my lost confidence and also recognizing that part of nuanced and critical thinking is (sometimes) getting things wrong, and sometimes right but too soon. So, I want to share both what I might be thinking that is wrong and also my worries about the nursing profession that I love so much. After nearly 20 years in this profession across specialties like orthopedic/trauma, medical/surgical units, mental health, public and community health, policy and education, I feel that I did my authentic best in trying to build the new and not getting lost in the challenges of the past. However, burnout happens to all of us, some more resilient than others. I am accepting that I might have pushed too hard for change and lacked the skills of relationship building. My past of being a refugee and immigrant female child who grew up in post-Communist Romania and Hungary could add to some of these reasons. The urgency to alleviate struggles for others was a real cause and drive for me. I never understood how a bunch of smart people could just sit around the table and talk about action, while people were struggling. Access to healthcare is access to people’s tax dollars. Talking was seemingly a waste of time from my perspective, as an early career public health nurse. I was searching to find people who felt the same urgency (or at least understood my motivations) as I did to act and help get folks out of poverty, get access to health and social services, and not just talk about it in meetings.

I may have been naïve and rushed. I was give the privilege of a profession to do good and alleviate harms. However, without trusted relationships, money doesn’t flow and people remain in poverty, in struggles that are the result of structures and systems I wanted to adapt. Some lessons we learn the hard way. I am now re-learning to build the confidence to talk, share ideas, and build relationship among people who are looking to advance the only huma-centered profession still remains. (I might be biased in this view) Is the last human job a nurse? Or so I assume in this manifesto. Or maybe the last human jobs are human-collaborations across sectors. Yes, that sounds more like it. But first we need to pivot (yes, just like that couch on a Friends episode from Feb 1999) and pay those human-collaboration jobs a fair wage.

Therefore, I am using my LinkedIn platform to share my ideas of A Nursing Manifesto for 2030: Human Care Against Extraction and Exploitation – a draft (2026) paralleling what has been written in 2000 and adding in some of my ideas from the list of resources that I will share at the very end of this writing. It might give future nurses in undergraduate and graduate studies something to ponder beyond the status quo of the nursing/ healthcare profession and education. We need to get out of ‘our’ status quo cultural box.

As always, I am open to discussions and opposing views that are shared respectfully.

1. INTRODUCTION

‘We’ are nurses (diverse with complex/ adaptive skills professionals) at a time when care is being remade by machines, markets, and systems that measure human worth in data points, risk scores, productivity targets, and billing codes.

We do not reject technology.

We reject technology without accountability.

Artificial intelligence, automation, surveillance, and predictive systems have entered hospitals, homes, clinics, long-term care, and public health. They promise efficiency while too often deepening abandonment. They sort people by profitability, automate denials, intensify workloads, erase human judgment, and place the burdens of flawed systems on those already made vulnerable by racism, colonialism, poverty, disability, gender oppression, and displacement.

We have seen what happens when an algorithm is treated as neutral while it inherits the inequities of the world that trained it. We have seen staffing systems call exhaustion as ‘optimization’. We have seen virtual care become a substitute for accessible, relational care. We have seen automation used not to relieve nurses of harmful labour, but to eliminate jobs, deskill practice, and demand that fewer workers do more with less.

This is not innovation.

It is extraction.

We are nurses practicing amid converging emergencies: widening inequality, climate breakdown, poisoned water, forced displacement, worsening chronic illness, automated exclusion, and healthcare systems increasingly governed by commercial interests rather than public need.

We affirm that health is inseparable from the conditions in which people are born, grow, work, live, age, and die. Health begins with breathable air, safe homes, nourishing food, clean water, meaningful connection, cultural continuity, freedom from violence, and a stable living planet. No hospital, algorithm, drug, or procedure can compensate for a society that systematically destroys these foundations.

The medical-industrial complex has transformed illness into revenue, crisis into market opportunity, and health into a commodity distributed according to wealth, insurance status, postal code, citizenship, and institutional power. It profits from endless treatment while neglecting clean air, safe housing, food security, living wages, disability justice, mental health, reproductive freedom, and the conditions that allow people to live well before they become patients.

We reject the fiction that health care exists apart from the world. The same systems that commodify illness extract from workers, communities, lands, and waters. The medical-industrial complex profits from treatment while underinvesting in prevention; corporations profit from pollution while public systems absorb the resulting disease; technology firms market “innovation” while shifting social, environmental, and clinical risks onto patients, caregivers, and frontline workers.

This is not an accident. It is a political choice.

We refuse to accept a healthcare system that calls itself advanced while people wait in pain, workers burn out and become patients themselves (Chapman, 2023), communities are poisoned, and the planet warms. (Check out the underlying drivers of planetary harms by Planetary Health Alliance website: culture, values, behaviour, consumption, population size/demographic changes, technology) https://planetaryhealthalliance.org/what-is-planetary-health/

Nursing must be more than the human face placed on an inhumane system. Our role is not to make austerity appear compassionate, to absorb the moral injury created by unsafe conditions, or to quietly compensate for decisions made by executives, insurers, technology firms, regulators and governments far from the bedside.

Our ethical obligation is to care and to confront what makes care impossible.

2. Planetary Health is Nursing Work

Planetary health is not an optional specialty or a future concern. It is present in every heat-related illness, asthma exacerbation, contaminated water supply, food insecurity assessment, infectious-disease outbreak, wildfire evacuation, pregnancy complication, mental-health crisis, and preventable death.

We recognize the health of people as inseparable from the health of lands, waters, ecosystems, and climate. Indigenous peoples have long carried knowledge of these relationships and of stewardship, reciprocity, and collective responsibility. Nursing must listen, learn, and act without appropriating that knowledge or repeating colonial systems of control.

We will advocate for health systems that reduce rather than export harm: low-carbon care, ethical procurement, less waste, resilient infrastructure, safe transportation, sustainable food systems, and emergency planning led with (not imposed upon) affected communities.

Clean water is a health right, not a commercial asset. Water insecurity, contamination, privatization, boil-water advisories, drought, flooding, and inadequate sanitation are nursing concerns because they produce infection, chronic disease, reproductive harm, trauma, displacement, and death. We will name water injustice as a clinical and public-health emergency, especially where it follows colonial dispossession, industrial pollution, and neglect of rural, remote, and Indigenous communities.

3. Commercial Determinants of Harm and Health: Get Political

We confront the commercial determinants of health: the corporate practices that shape exposure to harm, access to care, public policy, and the very definition of health.

Industries profit when people consume products that damage their bodies or environment, including tobacco and nicotine corporations, alcohol producers, ultra-processed food companies, fossil-fuel industries, extractive mining interests, pharmaceutical monopolies, private equity firms, surveillance platforms, and vendors of unaccountable health technology, and digital-addictive designs and digital-afterlife industries. Their influence reaches advertising, research, regulation, education, political lobbying, clinical guidelines, and data infrastructure.

We reject the normalization of harm as “consumer choice” when choices are engineered through marketing, pricing, scarcity, misinformation, racism, design inequity and unequal power.

We also recognize that commercial power can shape health positively only when it is democratically governed, transparent, and subordinated to the public good. Products, technologies, and services must be assessed not simply by revenue or technical novelty, but by their effects on equity, ecological sustainability, worker safety, community control, and long-term health. (my favourite slogan: war brings neither peace nor climate justice, defund military spending).

4. Nursing Is Not a Buffer for System Failure

Nursing is not low-paid emotional labour designed to absorb the failures of health and social systems. It is not a flexible reserve workforce to be stretched during crises, disciplined through precarity, or replaced by automation when budgets demand it.

Nursing knowledge is scientific, relational, ethical, political, and ecological. Nurses assess changing conditions, interpret uncertainty, build trust, notice patterns others miss, coordinate care across fragmented systems, protect rights, respond to suffering, and advocate for structural change. This expertise cannot be reduced to tasks, scripts, dashboards, or a layer of “human oversight” added after an algorithm has already shaped a person’s options.

We reject the use of artificial intelligence and automation to intensify work, monitor workers, remove professional judgment, automate benefit or treatment denials, or redirect accountability away from corporations and institutions. A nurse must never be expected to legitimize a harmful system simply because a person remains nominally “in the loop.”

Technology must serve care, not govern it. Any system used in health care must be transparent, independently audited, accessible, privacy-protective, environmentally accountable, and open to challenge by patients, families, nurses, and communities. It must be assessed for bias, labour impacts, energy and water use, supply-chain harms, and effects on access, not only for accuracy or cost savings.

5. Against the Medical-Industrial Complex

The medical-industrial complex converts suffering into revenue. It treats health as a market, patients as customers, records as assets, and workers as costs to be minimized. It normalizes private equity, monopolies, predatory pricing, medical debt, pharmaceutical profiteering, commercialization of data, and the outsourcing of public responsibilities to corporations.

We refuse a health system that boasts of technological progress while people cannot obtain primary care, medication, safe housing, home care, reproductive services, mental-health support, palliative care, or culturally safe care.

We oppose austerity disguised as efficiency. We oppose privatization disguised as innovation. We oppose surveillance disguised as safety. We oppose extraction disguised as care.

A just health system must be universal, public, adequately funded, community-rooted, culturally safe, accessible, and accountable to the people it serves. It must invest upstream: in income security, public housing, education, food sovereignty, disability justice, harm reduction, clean water, healthy ecosystems, and meaningful public-health capacity.

6. Our Commitment

We therefore commit ourselves to:

• Defend human dignity over speed, profit, automation, and institutional convenience.
• Defend health as a collective right and reject its treatment as a commodity.
• Identify and confront commercial practices that produce illness, environmental destruction, inequity, and barriers to care.
• Follow the leadership of communities most affected by environmental injustice, commercial exploitation, and institutional neglect.
• Insist that every artificial intelligence system used in health care be transparent, independently audited, explainable, contestable, and governed with meaningful public and worker participation.
• Refuse algorithms that reproduce discrimination or replace clinical judgment, informed consent, and relationships of trust. Stand against racism, colonialism, ableism, sexism, homophobia, transphobia, class exploitation, and xenophobia in health systems and society.
• Demand that technology reduce harmful work and expand access to care, not intensify surveillance, cut staffing, deskill nursing, or deny services. My post on nursing profession and branding https://www.linkedin.com/feed/update/urn:li:activity:7496682545108025345/
• Organize for safe staffing, fair wages (like programmers and coders once were paid), public health infrastructure, union rights, and workplaces where nurses can speak honestly without retaliation (regulatory harms have still not been addressed explicitly and attrition continues to crisis levels). My post on trauma: https://www.linkedin.com/feed/update/urn:li:activity:7496346149822287873/ ; my post on regulatory harms https://www.linkedin.com/feed/update/urn:li:activity:7496353936921071616/
• Treat climate disruption as a health emergency created by unequal systems of extraction, and advocate for care that protects communities and the living world.
• Stand with patients and communities against medical debt, privatization (yes Canada, you too), predatory pharmaceutical practices, corporate consolidation, and the commodification of suffering (CDoH, 2022). post on global power demand by 2030 https://www.linkedin.com/feed/update/urn:li:share:7255265303691997184/
• Advocate for public, universal health systems free from corporate capture and private-profit priorities.
• Center the knowledge and leadership of Indigenous peoples, Black communities, disabled people, migrants, low-income communities, and all those harmed first and worst by unequal systems. (Can we please collect wealth tax, and stat? Harrington, 2025)
• Protect the right of every person to understand, question, and refuse the technologies affecting their body, records, treatment, and future. (Once people lose mental capacity, at any age, what happens to their digital footprint and logins. Read up on digital-afterlife industry) my post: https://www.linkedin.com/feed/update/urn:li:activity:7496323674120048640/
• Practice solidarity across professions, sectors, and borders, because no individual nurse can solve harms produced by structural power.
• Protect clean water, sanitation, healthy ecosystems, and climate stability as indispensable conditions of health.
• Treat nursing expertise as essential to governance, policy, technology design, climate adaptation, public health, and community-led care, not as inexpensive labour or an afterthought in executive decisions.
• Build care systems based on solidarity, reciprocity, prevention, justice, and ecological repair.

7. A Call to Conscience and Action

In 2030, conscience requires more than compassion.

It requires courage. Not only to speak for/with patients, families and communities, but to speak against professional toxic culture, leadership, and stagnant professional envelopment. It requires collective action against the systems that manufacture illness and call the consequences unavoidable.

It requires us to ask not only, “Can this technology be used?” but “Who does it serve? Who exposed to/ bears its risks? Who profits? What forms of care, labour, and life does it displace?” Who is left waiting, excluded, displaced, or silenced?

I have held a role as a nurse informatics, merging duplicate files because IBM refused to adapt their infrastructure. Are informatics professionals seen as human-in-the-loop or human-exploited-in-the-loop?

It requires us to understand that a healthy society cannot be built on exhausted workers, disposable patients, automated exclusion, or a damaged planet. We CAN however, pivot workforce roles and pay people to do human jobs, like witnessing and delivering care where it’s needed. (Pugh, 2026)

Care cannot be ethical if it relies on ecological destruction. Innovation cannot be just if it is built on surveillance, dispossession, or underpaid labour. Health cannot exist where water is unsafe, homes are unaffordable, ecosystems are collapsing, and human needs are subordinated to corporate return.

We will not be reduced to exhausted labour, automated compliance, or human cover for decisions made by machines and markets.

We call on nurses to reclaim our collective (yet, diverse) voice. We call on health workers to organize. We call on institutions to place care above revenue (wealth tax helps here). We call on governments to regulate health technologies in the public interest and to fund universal, accessible, community-rooted health care.

We call on the public to reject a future in which the right to health is determined by an algorithm or a balance sheet.

Care is not a product. Health is not a privilege. People are not (just) data to be extracted and sold.

The planet is not expendable.

We will not be silent witnesses to systems that harm in the name of progress.

We will practice, organize, resist, and build a future in which care remains human, collective, just, and sustainable.

We are nurses. We are advocates, clinicians, educators, organizers, researchers, knowledge holders, and defenders of the conditions required for life.

We will care for people and we will fight for the world in which people can be well.

8. About the Author

The Nursing Manifesto 2030 builds upon and expands The Nursing Manifesto 2000, the pioneering work of Richard Cowling, Sue Hagedorn, and Peggy Chinn. In the age of AI, provenance is one of the most important forms of acknowledgement, demonstrating that ideas and thoughts never simply appear, but are cultivated, grazed, turned over, and digested with time, patience, and communal support. The original authors all came from white, middle-class backgrounds and grew up in diverse regions of the United States (New York, Hawaii, Virginia), with relatively privileged access to education, travel, and cultural experiences. Yet early in their lives, each followed personal and political paths that challenged the status quo, often to the chagrin of family and friends. Though not always overtly “political” on the surface, their journeys reflected a deep yearning for peace, justice, and the caring, nurturing values they perceived to be at the heart of nursing. They came together to prepare the text for A Nursing Manifesto 2000, informed by their shared awareness of the deeply political nature of personal choices.

Renata E. Mares, author of The Nursing Manifesto 2030: Human Care Against Extraction and Exploitation (green paper), brings both continuity and distinct difference to this legacy. Born in 1984 in Oradea, Romania, a region marked by Hungarian legacies and Romanian cultural tensions since the 1920s (Treaty of Trianon), she became a refugee at age four when her family fled the communist regime in 1988. She grew up in post-communist Hungary (schooling) and Romania (summer vacations), experiences that shaped her social justice and ethical compass, and led her to challenge oppressive and racist systems throughout her nursing career. Her father and brother spend fiver years (1990-95) in Rochester, New York in hopes for her mother and herself to follow but at that time families could not easily join. Her family immigrated to Guelph, Ontario, Canada in 1996 and has called this place home even across her decades of travel and nursing. Since nursing school in Canada (2003–2008) and continuing through diverse roles in ortho-trauma, med-surg, rehabilitation, mental health, long-term care, public health, outbreak management, policy consulting, education, and global humanitarian work (2009–2019), she has consistently challenged the status quo, even when it meant alienating friends, colleagues, and family. 

Today, she firmly believes nursing and healthcare remains the most human-centered profession, uniquely positioned to challenge profiteering practices, build regulatory and safety guardrails through healthy public policy, and resist automation of human-care work. Grateful to the original manifesto authors for helping her articulate the political nature of her own choices, she writes in hopes that reflection, awareness, and philosophy will offer others the same healing she has found through two decades of honest practice in nursing and across the health system.

9. References

Alicia Wanless. The Information Animal: Humans, Technology and the Competition for Reality. 2025. https://academic.oup.com/book/61821.

Alison Pugh. The Last Human Job. 2026. https://press.princeton.edu/books/hardcover/9780691240817/the-last-human-job?srsltid=AfmBOoq_JMH6DnzyIEP2cMrGLQaAsBUtcxJWMy439dXRkiXxKJRId0CX.

Arthur Allen. Vaccine: The Controversial Story Of Medicines Greatest Lifesaver. WW Norton, 2008.

“Automating Inequality.” Virginia Eubanks, August 19, 2017. https://virginia-eubanks.com/automating-inequality/.

Bartlett, Cheryl, Murdena Marshall, and Albert Marshall. “Two-Eyed Seeing and Other Lessons Learned within a Co-Learning Journey of Bringing Together Indigenous and Mainstream Knowledges and Ways of Knowing.” Journal of Environmental Studies and Sciences 2, no. 4 (2012): 331–40. https://doi.org/10.1007/s13412-012-0086-8.

Bessel van der Kolk. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books Canada Limited, 2015.

Brian Evergreen. Autonomous Transformation: Creating a More Human Future in the Era of Artificial Intelligence. 2023. https://www.amazon.ca/Autonomous-Transformation-Creating-Artificial-Intelligence/dp/1119985293.

Brooke Harrington. Offshore: Stealth Wealth and the New Colonialism. 2025. https://www.penguinrandomhouse.ca/books/773970/offshore-by-brooke-harrington/9781324110323.

Cory Doctorow. The Reverse Centaur’s Guide to Life After AI. 2026. https://www.versobooks.com/en-ca/products/3584-the-reverse-centaur-s-guide-to-life-after-ai.

Costanza-Chock, Sasha. Design Justice: Community-Led Practices to Build the Worlds We Need. Information Policy, edited by Sandra Braman. MIT Press, 2020. https://mitpress.mit.edu/9780262043458/design-justice/.

Daniel Susskind. “A World Without Work.” Accessed August 22, 2026. https://www.danielsusskind.com/a-world-without-work.

David Graeber and David Wengrow. The Dawn of Everything. 2023. https://www.penguinrandomhouse.ca/books/616885/the-dawn-of-everything-by-david-graeber-and-david-wengrow/9780771049842.

Emily M. Bender and Alex Hanna. The AI Con: How to Fight Big Tech’s Hype and Create the Future We Want. 2025. https://thecon.ai/.

Gabor Maté. When the Body Says No: The Cost of Hidden Stress. 2004. https://drgabormate.com/book/when-the-body-says-no/.

Gary Slutkin. The End of Violence. 2026. https://www.hachettebookgroup.com/titles/dr-gary-slutkin-md/the-end-of-violence/9780316520119/.

Gregory P. Marchildon. Tommy Douglas and the Quest for Medicare in Canada. 2024. https://utppublishing.com/doi/book/10.3138/9781487560430.

Haun Saussy, ed. Partner to the Poor: A Paul Farmer Reader. 1st ed. University of California Press, 2010. https://www.jstor.org/stable/10.1525/j.ctt1ppcmr.

“Invisible Women | Caroline Criado Perez.” Accessed August 22, 2026. https://carolinecriadoperez.com/book/invisible-women/.

John Ralston Saul. On Equilibrium. 2001. https://www.amazon.ca/Equilibrium-John-Ralston-Saul/dp/0140288031.

Karen Hao. Empire of AI. Penguin Random House Canada. 2025. https://www.penguinrandomhouse.ca/books/743569/empire-of-ai-by-karen-hao/9780593657508.

Leanne Betasamosake Simpson. Theory of Water: Nishnaabe Maps to the Times Ahead. 2026. https://www.leannesimpson.ca/portfolio-books/theory-of-water.

Linda McQuaig and Neil Brooks. Cancelling Billionaires Before They Cancel Us. 2026. https://www.dundurn.com/books_/t22117/a9781459754836-cancelling-billionaires-before-they-cancel-us.

Maude Barlow. Profit Is Not the Cure by Maude Barlow | Penguin Random House Canada. 2011. https://www.penguinrandomhouse.ca/books/8670/profit-is-not-the-cure-by-maude-barlow/9781551995267.

Maude Barlow and Tony Clarke. Blue Gold : The Battle Against Corporate Theft of World’s Water. 2003. https://www.penguinrandomhouse.ca/books/8669/blue-gold-by-maude-barlow-and-tony-clarke/9780771010866.

Mehra, Natalie, and John Cartwright. “Profit Is Not the Cure.” The Council of Canadians, April 12, 2024. https://canadians.org/analysis/profit-is-not-the-cure/.

Nason Maani, Mark Petticrew, and Sandro Galea. The Commercial Determinants of Health. Oxford University Press, 2022. https://academic.oup.com/book/44473.

Noral Loreto. Corporate Control. 2025. https://www.dundurn.com/books_/t22117/a9781459753136-corporate-control.

Paul Farmer. AIDS and Accusation: Haiti and the Geography of Blame. 2nd ed. University of California Press, 2006. https://www.jstor.org/stable/10.1525/j.ctt1pp3p4.

Paulo Freire. Pedagogy of the Oppressed. 50th ed. 2018. https://www.bloomsbury.com/ca/pedagogy-of-the-oppressed-9781501314162/.

Renee DiResta. Invisible Rulers. 2024. https://www.hachettebookgroup.com/titles/renee-diresta/invisible-rulers/9781541703377/?lens=publicaffairs.

Richard Cowling, Peggy Chinn, and Sue Hagedorn. “A Nursing Manifesto: A Call to Conscience and Action.” NurseManifest, 2000. https://nursemanifest.com/a-nursing-manifesto-a-call-to-conscience-and-action/.

Robert Chapman. Empire of Normality. 2023. https://www.plutobooks.com/product/empire-of-normality/.

Robin Wall Kimmerer. Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge and the Teachings of Plants. 2015. https://www.amazon.ca/Braiding-Sweetgrass-Indigenous-Scientific-Knowledge/dp/1571313567.

Shoshana Zuboff. The Age of Surveillance Capitalism. 2019. https://www.hachettebookgroup.com/titles/shoshana-zuboff/the-age-of-surveillance-capitalism/9781610395694/?lens=publicaffairs.

Tim Ingold. Anthropology: Why It Matters. 2018. https://www.wiley.com/en-us/anthropology-why-it-matters-p-9781509519804.

Tina D. Purnat, Tim Nguyen, and Sylvie Briand, eds. Managing Infodemics in the 21st Century: Addressing New Public Health Challenges in the Information Ecosystem. Springer, 2023. http://www.ncbi.nlm.nih.gov/books/NBK609023/.

Vanessa de Oliveira Andreotti and Rene Suša. “Meta-Relationality Institute & Clearing the Field Series.” Meta-Relationality Institute, July 25, 2025. https://metarelationality.institute/about/.

Vanessa Machado de Oliveira. Outgrowing Modernity. 2025. https://www.penguinrandomhouse.ca/books/783178/outgrowing-modernity-by-vanessa-machado-de-oliveira/9798889842507.

“What Is Planetary Health?” Planetary Health Alliance, September 5, 2017. https://planetaryhealthalliance.org/what-is-planetary-health/.