Inequalities of Aging: Paradoxes of Independence in American Home Care

Inequalities of Aging: Paradoxes of Independence in American Home Care. Elana Buch, New York: NYU Press, 2018, 288 pp.

Elana Buch’s Inequalities of Aging: Paradoxes of Independence in American Home Care is a masterful ethnography of paid home eldercare in Chicago that richly deserves the attention of medical anthropologists. The book provides a vivid portrait of the intimate but fraught and often precarious relationships that constitute paid home care in the United States, and it makes important contributions to advancing the state of several discussions in our field: about the meaning and experience of sickness and aging; about the political–economic and cultural context of care practices and access to care; and about the critical analysis of health-related policies.

For those who may not (yet) have personal experience with paid home care for the elderly, Inequalities of Aging offers an eye-opening introduction to this large and important but largely hidden domain of care work. Paid home care for the elderly is a critical part of the U.S. health care “system” and an important sector of the economy, but because it takes place in private homes, it is less visible and less readily accessible to researchers than care provided in nursing homes, hospitals, and other institutions. Home care workers provide the supportive services (from bathing, laundry, and administration of medications, to cooking, housework, and more) that allow older adults to continue living in their own homes, as so many ardently wish to, in the face of health challenges and waning capacities that render their independence precarious. Buch’s book focuses on home care workers who are hired, trained, employed, and supervised by two different agencies in the city of Chicago. One is a private company that provides privately funded care. The other is an agency contracted by the state to provided need-based services to low-income clients. Through interviews and ethnographic observations carried out in these two quite different agencies, across such different settings as a worker training session, care supervisors’ workplaces, clients’ homes, care workers’ own homes, and the various other settings into which care workers move (grocery stores, hospital waiting rooms, and more), Buch develops a powerful and original analysis that highlights the embeddedness of home care work within systems of inequality.

The “paradoxes of independence” referred to in the book’s subtitle flow from the author’s insight that independence, though generally conceptualized as a (highly morally valued) attribute of individuals, is, in fact, a profoundly social and relational accomplishment. Buch shows how independence is socially produced, how the costs and consequences of this work ramify, and how both this work and its ramifications get hidden from view.

Older adults whose infirmities impact their ability to perform the tasks necessary to maintain their everyday lives rely on paid care workers to provide crucial support. Through their attentive care practices, these workers actively sustain the subjectivity, personhood, and independence of their elderly clients, enabling them to live valued lives. To do so, they draw on not only their moral imagination and capacity for empathy, but also on their own embodied senses and on the knowledge and skills developed within their own lives, families, and communities. Buch refers to the care practices as “generative labor,” meaning the moral imaginings, practices, and relations through which people work together to generate life—a concept that extends feminist insights developed in the context of discussions of reproductive labor, to encompass the forms of care work necessary to sustain human beings throughout the life span.

The great paradox of paid home care work, as Buch powerfully argues, is that under current political–economic and social arrangements around home care, the workers whose generative labor enables older adults to remain independent find it exceedingly difficult to live up to societal expectations of independence in their own lives. The workers profiled in Buch’s study struggle to sustain their own families in the face of low wages, difficult schedules, long commutes, and the many other challenges of racialized poverty and segregation. Many have been pushed into home care work as a consequence of welfare-to-work policies that channel their caring labor away from their own families and into this low-paid work for others. Yet their commitment to creating a sense of independence for their elderly clients leads the workers to strive to keep the difficult realities of their own lives hidden from their clients’ awareness. Agency policies also forbid workers from discussing their private troubles in the workplace. The care practices, relationships, and policies that produce independence for older adults thus deny to home care workers themselves the conditions that would allow them to achieve independence, while also helping make their struggles invisible. In this respect, Inequalities of Aging joins a growing literature that documents how relations of care can be entangled with forms of violence.

The analysis presented in Inequalities of Aging is informed by thoughtful engagement with scholarly discussions of race, labor, gender, family, home, embodiment, and care as these have emerged in a range of neighboring disciplines. Inequalities of Aging brings them together within a very powerful vision, at once intellectual and political, that reveals population aging and increasing social inequality as deeply intertwined phenomena. Along the way, the book also engages with the anthropological tradition of thinking on such classical topics as liminality, gift exchange, personhood, and embodiment. At every turn, the book turns a gaze that is both critical and compassionate on the people whose lives are sustained and constrained through their involvements with paid home health care.

The book’s focus specifically on paid home care in Chicago means that it does not address every aspect or circumstance of eldercare. Older adults with severe cognitive impairment or those who required live-in care, and the care workers who attend to them, were not included in the study; nor are transnational migrant workers, rural care workers, or undocumented care workers. These limitations notwithstanding, Inequalities of Aging is a singular achievement of methodological rigor, theoretical sophistication, compelling analysis, and beautiful writing. The book exemplifies the very best potential of careful, sensitive ethnographic research to generate surprising and challenging insights on a topic of pressing public concern. As such, it will lend itself well to teaching at both the undergraduate and graduate level, and I expect that it will have a very wide influence.

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