Troubling Gifts of Care: Vulnerable Persons and Threatening Exchanges in Chicago’s Home Care Industry

Abstract

By tracing the transformations of troubling exchanges in paid home care, this article examines how differently positioned individuals strive to build caring relations within potentially restrictive regimes of care. In paid home care in Chicago, older adults and their workers regularly participate in exchanges of money, time, and material goods. These gifts play a crucial role in building good care relationships that sustain participants’ moral personhood. Amid widespread concern about vulnerable elders, home care agencies compete in a crowded marketplace by prohibiting these exchanges, even as they depend on them to strengthen relationships. Supervisors thus exercise discretion, sometimes reclassifying gift exchanges as punishable thefts. In this context, the commodification of care did not lead to the actual elimination of gift relations, but rather transformed gift relations into a suspicious and troublesome source of value.

Author Biography
Elana D. Buch is an assistant professor of anthropology at the University of Iowa. Her research examines the complex intersections of caregiving and power in later life. Drawing on approaches from medical anthropology, social work and feminist anthropology, Buch’s work examines the ways that emerging forms of care and everyday care practices shape both intimate and political social relations. She is particularly interested in the ways that care practices naturalize, reproduce or transform social inequalities. Her research is focused in the United States, where discourses of productivity and independence crucially shape the social roles and forms of care available to older and disabled adults.

Additional Publications by the Author
Buch, E. D., & Staller, K. M. (2007). The Feminist Practice of Ethnography. Feminist Research Practice: A Primer. Sharlene Nagy Hesse-Biber, Patricia L. Leavy, eds. Pp. 187-221. Sage Publications.
Buch, E. D. (2013). Senses of Care: Embodying Inequality and Sustaining Personhood in the Home Care of Older Adults in Chicago. American Ethnologist, 40(4), 637-650.
Buch, E. D. (2015). Postponing Passage: Doorways, Distinctions, and the Thresholds of Personhood among Older Chicagoans. Ethos, 43(1), 40-58.

The Beauty of Old Age, by Vinoth Chandar, March 5, 2013.

The Beauty of Old Age, by Vinoth Chandar, March 5, 2013.

Editorial Footnotes
If you liked this article, you might also be interested in the previously published articles in Medical Anthropology Quarterly on care by Denise L. Spitzer (2004) In Visible Bodies: Minority Women, Nurses, Time, and the New Economy of Care, Susan J. Shaw’s (2005) The Politics of Recognition in Culturally Appropriate Care, and Laura Lynn Heinemann’s (2014) For the Sake of Others: Reciprocal Webs of Obligation and the Pursuit of Transplantation as a Caring Act.

In addition, Medical Anthropology Quarterly has several previously published articles on aging, such as Emily Wentzell’s (2013) Aging Respectably by Rejecting Medicalization: Mexican Men’s Reasons for Not Using Erectile Dysfunction Drugs, Gay Becker and Sharon R. Kaufman’s (1995) Managing an Uncertain Illness Trajectory in Old Age: Patients’ and Physicians’ Views of Stroke, Mark R. Luborsky’s (1994) The Retirement Process: Making the Person and Cultural Meanings Malleable, and Karin Johansson’s (2013) Have They Done what They Should? Moral Reasoning in the Context of Translating Older Persons’ Everyday Problems into Eligible Needs for Home Modification Services.

Interview with the author

How did you become interested in home care services in Chicago?
I grew up outside Detroit, my parents were heavily invested in serving the community where we lived and I had an awareness of class politics from an early age. When I started graduate school, “welfare reform” legislation had only just been passed, pushing low-income mothers into the formal labor force. Most women who previously qualified for welfare were forced to take low-wage, contingent service jobs like home care. These jobs are a new riff on older forms of white middle/upper class domesticity and domestic service that in earlier moments were reinforced by segregationist policies. Chicago is in many ways the classic U.S. city for studying race, class and inequality. My project builds on this legacy, but also challenges the notion that poor folks of color are trapped in Chicago’s segregated neighborhoods by highlighting the vital role these workers play in the life of the city.

At the beginning of graduate school, my grandmother’s health declined and my grandfather hired a home care worker to help him care for her. Their relationships were strange and fascinating. I saw that home care deserved the kind of sustained attention to relational complexity and daily practices possible in ethnographic research. Studying aging at a time when both the national and global populations are growing older offers social scientists the opportunity to study a new human experience – never before have so many people lived so long. Anthropologists have a real opportunity to offer alternative perspectives to discourses that focus on the costs of population aging. My work highlights the fragile interdependencies that undergird current forms of elder care, showing how they are both built upon and destabilized by long legacies of inequality.

How did your status as a social worker-anthropologist shape your interactions with home care workers and older adults?
My status and training as a social worker influenced both how people perceived me and how I came to think about fieldwork relationships. In some of the neighborhoods where I worked, the only young white women around were either social workers or researchers. My role was already so over-determined that people teased me about it. I’m guessing that the long legacy of white women social workers inspecting and judging the homes, lives and parenting of women of color was an unspoken reason some people were reluctant to participate in the project.

When I started fieldwork, I thought I should participate and help out in any way that people let me. Soon, one homebound elder asked me to pick up her prescriptions and a couple of groceries at the drug store before my visit. Not a big deal. A few months later, I was doing all of her grocery shopping and prescription pick-ups. I would worry when I went out of town that she would go hungry, and wasn’t sure how she would manage when I left Chicago at the end of fieldwork. My field notes from those days show me wanting to avoid her, struggling with being needed in ways I couldn’t possibly fulfill. Those notes are full of shame and frustration. After that, I started drawing more on the ways that social workers manage boundaries, which meant recognizing that it wasn’t okay for me to play such a central role in her life. This was not only because of the emotional toll it took, but because in the long run I was making possible for her and the agency to avoid getting her more help.

Walking by Abdulsalam Haykal, September 28, 2011

Walking by Abdulsalam Haykal, September 28, 2011

In the background section, you break down different trajectories within the anthropology of care literature. Would you consider this area a productive platform for medical anthropology? What do you consider to be some of its key contributions as well as limitations? What do you think needs to be added?
Care is a generative topic, in part because the term can mean so many things – it challenges us to understand what is common, or not, across a broad range of spatial and temporal scales from intimate, everyday practices to national and global policy. While thinking about care often intersects with thinking about health and medicine, it also pushes us to think about how some kinds of people, activities, outcomes etc., come to matter, or matter in different ways, while others do not. By doing this, the anthropology of care is pushing medical anthropology to theorize morality and moral practice in new ways.

The multiplicity of meanings conveyed by the term ‘care’ is also one of the challenges of thinking comparatively and analytically with this term. The word care, in English, carries deep moral connotations about the links between emotion and action. I think we need to be asking how/why/what do we presume about the relationships between morality, affect and practice when we talk about care? We need to continue doing nuanced, comparative work to help us figure out whether “care” is analytically useful as we move it across diverse contexts, or at least what it means when it does.

Relatively little recent medical anthropological work on care engages explicitly with the feminist literature analyzing social reproduction as key site for the production of inequality. I would like to see medical anthropologists integrate these analyses into our discussions – to think about the connections between who cares and how care is practiced, and these processes are implicated in forms of difference and inequality.

Outside of family member reporting of gift exchanges between their relatives and home care workers, did you witness any other tension between family members and home care workers? On the flip side, were there any instances in which home care workers and family members worked together to provide care for older adults?
Friction is part of the collaboration between home care workers and elders’ kin. In one case a home care worker told me that when we went to the grocery store, her elderly client should push the cart – using it as a kind of improvised walker in case the older woman tired. When I went to the store with the older woman and her daughter, her daughter was horrified when I handed the cart to her mother, and told me emphatically “She doesn’t push!” – suggesting that it was rude of me to ask her frail mother to do tiring work. Family care carries with it the weight of long relational histories that shape how kin care – in the case above, the daughter was trying to protect and show deference to her mom by relieving her of the work of pushing. Workers, on the other hand, are hired to help older adults remain independent, including by relieving kin of the ‘burdens’ of care. In the example, the worker helped her client feel independent by having the older woman push the cart, which disguised her frailty and gave her way of contributing to the activity. These same kinds of frictions appear when kin and workers collaborate face-to-face – they can be both generative and destructive for caring relationships and the people involved.

What projects are you working on now?
I am working on two projects. The first, State of Care, focuses on veteran’s long-term care, comparing the experiences of caregiving in pre- and post-9/11 populations in the U.S. Social policies emerging in the aftermath of war, both in the U.S. and elsewhere, have shaped the role of the state and the social contract for generations. Examining how veterans and their caregivers experience care and make claims on the state may help us understand new political formations. The second project, New Love in Later Life, focuses on the experiences of older adults who form new committed relationships and/or get married in later life. Social support is so important for health and well being in later life, but we don’t know that much about how these kinds of new family formations are connected to concerns about social support. I am interested in the complexities of intimate relationships that start in later life, how these differ from those at other points in the life course, and how other kin react to these relationships.

Elderly by Kevin Dooley, August 3, 2008

Elderly, by Kevin Dooley, August 3, 2008

Questions for Classroom Discussion
1. Considering the caregiving relationship between Doris and Mr. Thomas, do you consider the monetary exchanges as theft? Why or why not?
2. What factors influence the U.S. home care industry? Consider political and economic contexts as well as demographic characteristics of the home care workers.
3. Does home care individualize suffering and vulnerability, as argued by Buch?

Additional Resources
Cartier, C. (2003). From Home to Hospital and Back Again: Economic Restructuring, End of Life and the Gendered Problems of Place-Switching Health Services. Social Science and
Medicine, 56(11), 2289–2301.
Mol, A. (2008). The Logic of Care: Health and the Problem of Patient Choice. London: Routledge.
Russ, A. J. (2005). Love’s Labor Paid For: Gift and Commodity at the Threshold of Death. Cultural Anthropology, 20(1), 128–155.
Yates-Doerr, E. (2011). The Weight of the Self: Care and Compassion in Guatemalan Dietary Choices. Medical Anthropology Quarterly 26 (1), 136–158.