By Clare L. Stacey
Cornell University Press, 2011

Reviewed by Jeanne Bryner

 

The Obama administration is negotiating a new trade agreement, the Trans-Pacific Partnership (TPP), that may lower tariff and investment barriers in low-cost production nations—including Vietnam. Simultaneously, the administration is promoting the idea of “reshoring” manufacturing, albeit for far lower wages for workers in the United States—a trend Sam Walton embraced in the early 1980s, even while he made Walmart one of the world’s largest importers. Third, recent investigations of working conditions in Chinese factories owned by Foxconn that assemble iPads, iPhones, and other gadgets for Apple have heightened public awareness of the plight of too many Chinese workers. Finally, Walmart executives are keenly aware of the company’s image problem, and have recently promised a more sustainable brand. If too many workers in both retail and manufacturing are too poor to shop at Walmart in China, the United States, or even Vietnam someday, the company’s entire business model collapses.

Taken together, these developments may change Walmart’s strategies. This book certainly provides the evidence that positive changes are necessary to ensure dignity, fair pay, and safe conditions for its retail workers and contracted factory labor. Or, in ten years, will we simply change the title of this book to Walmart in Vietnam?

As I sit down to write about Clare L. Stacey’s timely discussion of the daily grind of home caregivers, and the elderly or disabled people placed in their charge, my ninety year old mother-in-law’s face rises before me. An overweight, severely arthritic retired union retail clerk, she’s just been released from the hospital and moved to a rehab center. She survived an eight-hour bowel obstruction/perforation/resection surgery, and now she must attempt to regain enough strength to return to her own home. A wheel of plans must be formulated to help her maintain what seems to be a very teetering independence. Mother to twin girls and two sons, she has outlived both daughters. Not a day passes without her telling me, “I wish Darlene were here. She always said she’d take care of me.” This is the newest chapter of my mother-in-law’s life’s narrative, and it’s waiting for all of us. As I sigh and push her wild gray hair back from her forehead, I wonder who will bathe me, feed me, diaper me, and, if I’m really lucky, play a hand of rummy before waving me goodbye? Long-term care in the United States is a cloudy question and a crisis we’d rather not discuss. And what will become of the growing legions of disabled and elderly poor? If they are not in our own family, we may not pay attention to who provides care, how those caregivers are paid, how they are trained, and the agencies ultimately responsible for their actions. A medical sociologist, Stacey invested ten years in studying the experiences of home health care workers and their clients in California and Ohio. In this book, she presents their poignant, disturbing, and thought-provoking narratives as evidence to call us to think about work we would often prefer to ignore.

Stacey divides The Caring Self into four main areas: the costs of caring (real dollars, ratios of clients to caregivers and emotional currency), the physical and emotional labor of home care, the rewards of caring, and organizing home care. Instead of graphs, charts, and congressional debates, the book explores these issues through the voices of seasoned home care aides. Stacey provides a brief biography of each of the people she interviewed, followed by an honest account that presents the day-to-day work of care-giving in powerfully concrete terms. Here’s how one Ohio home health worker described her experience:

“I had a client over in Middletown. The lady had Alzheimer’s, which I dealt with. It was no problem. People were filthy, nasty, they had animals all in their house, feces. The son, which was lazy, he was a bum. Lived off of his parents. Cats, dogs, all through the house. Urine all through the home. Feces everywhere from the animals. Just filth. And the guy that lived there, the son, had a gun laid on the table. I put up with that for a year” (p. 49).

There’s a real immediacy in these narratives, which put us beside the caregivers and clients throughout the book. Through the interviews, Stacey demonstrates the emotional investment of this work, which she examines as a “resource” and “capital” for home caregivers. Drawing on feminist studies, Stacey shows the theory of circular emotional capital, tracing how girls are taught to be caregivers early in childhood and then carry that behavior pattern into the workplace. She gives us a snapshot of social psychologists’ theory that our work identities are rooted in race, class, and gender. Childhood plants the seeds for our life’s work, and Stacey points out that this “produces identity” while also “reinforcing inequality” (p. 36). It’s not surprising that all but five of the thirty-three workers Stacey interviewed are women. She reminds us that if the current trends continue, when I wonder about who will bathe and feed me when I’m old, I should imagine a poor immigrant or a woman of color.

Most of us prefer the idea of being cared for in our own homes rather than in an institution. We want our own bed, and we don’t care if the mattress sags. Stacey suggests that this preference also applies to caregivers. She draws on ethnographic research to highlight differences in the scope of work, financial rewards, and physical/emotional investments between home and institutional workers. Inside our homes and away from institutional supervisors, the lines of professionalism and familiarity blur. Every sore needs its dressing, and while caring for an oozing wound may be beyond the scope of an aide, if there’s no family, and if there’s no nurse, who will do it? Bowel movements of the sick may be coaxed or cursed, but after they’re done, someone must launder sheets and fold them. There will be complaints about a bad smell, and someone must lift the canister, and care enough to spray the room and bleach the potty chair. As the body in its decline is revealed, intimate spaces stripped, lathered and dressed, for better or me, and, if I’m really lucky, play a hand of rummy before waving me goodbye? Long-term care in the United States is a cloudy question and a crisis we’d rather not discuss. And what will become of the growing legions of disabled and elderly poor? If they are not in our own family, we may not pay attention to who provides care, how those caregivers are paid, how they are trained, and the agencies ultimately responsible for their actions. A medical sociologist, Stacey invested ten years in studying the experiences of home health care workers and their clients in California and Ohio. In this book, she presents their poignant, disturbing, and thought-provoking narratives as evidence to call us to think about work we would often prefer to ignore. Stacey divides The Caring Self into four mainworse, emotional ties are formed between home care aides and clients. Stacey shows us relationships that are both touching and horrifying. Imagine being stabbed by a client, seeking medical treatment, and then finding out you no longer have a job. This happened to one of Stacey’s interviewees. What about coming to work and having a client’s family member drop off fifteen loads of laundry? Or being asked to pick up and pay for medicines because your client has no money and no transportation? Some clients end up living with their aides because they are unable to exist on their disability funds.

Agencies count on these hard-working people to have compassionate hearts. Offering little compensation, agencies manage to steal precious hours and days from those caregivers. Why would a person sign on for this tour of duty? Over and over in Stacey’s interviews, home care aides report that they enjoy the autonomy of working in a home setting. The pace is more manageable than in an institutional setting and, most days, the outcomes are more predictable. Of course, wages and benefits figure into any job, but researchers and workers know that emotional rewards and autonomy help to recruit and retain employees. This physically exhausting and emotionally draining work attracts folks who have few other employment options. And once on board, the home care aides have limited upward mobility, low wages, few (if any) benefits, unpredictable schedules, and almost no labor protections. In the land of broken bodies, dysfunctional client families, and hard work, home care aides construct a purposeful life narrative from the positive and negative aspects of their days. They feel called to this service and find meaning and dignity in a job most people think of as “dirty.” As one of the interviewees recalled of the hospital aide who cared for her after childbirth, “This lady came, she took care of me, she cleaned me up… I will never forget those hands. That changed my life…  those hands were so special to me. So I wanted to care for somebody, too” (p. 13).

Home health care work is not without problems, of course, many of them driven by the complexities of local, state, and federal regulations (and lack of the same). It’s difficult to pin down the players in the shell game of responsibility and accountability in the world of home care aides and clients. Many public and private agencies create “consumer driven” contracts. This language binds the aides and clients, and relieves the agency of liability. The client supposedly trains, supervises, hires, and fires the aide. But how does a quadriplegic train his newly-hired aide to lift him safely to a shower chair? Even though the State of California issues paychecks for these aides, the aide is still contractually working for the client.

Unionization offers some hope, but it’s hard won. Home care aides are as scattered as birdseed, and that makes organizing them difficult. Many don’t understand what unions have to offer. Some have belonged to unions and see them as protecting the inadequate caregivers. They want to distance themselves from these bad apples and any arrangement that protects them. Education is the key to empowerment, and Stacey shows how the SEIU, National Home Care Workers, and now AFSCME in California started a wave of change (however rocky) for home care workers, leading to improvements in wages, benefits, and access to training. She and the caregivers she interviews also point to productive partnerships between the SEIU, the World Institute on Disability, the Centers for Independent Living, and the California Senior Legislature, with a focus on client care. Similar efforts have benefited workers in New York, Washington, and Oregon, but organizing is just getting started in Ohio.

Union organizers, attorneys, and students of labor history will find solid proof in this book that organizing caregivers is both possible and beneficial. Stacey’s book should also be required reading for legislators, medical students, social workers, nursing students, clergy, hospital administrators, dietitians, physical and occupational therapists, and all students of the humanities. Unflinching in its revelations, Stacey’s work delivers a punch, hits us full force, and leaves us shaking our heads with shame. Unless we heed these narratives and begin to create change, these are the rooms that will bear our names.