The Cultures of Caregiving: Conflict and Common Ground among Families, Health Professionals, and Policy Makers (review)

Carol Levine, MA, and Thomas H. Murray, PhD, together with 13 other highly acclaimed researchers and authors compiled this resource through discussions with health care professionals from several disciplines. The idea is to present an array of culturally-specific perspectives on giving care to people who are ill or disabled. The project was made possible by the United Hospital Fund and The Hastings Center.

Differing expectations of the health care system are often overlooked or poorly understood, and Levine and Murray's book is intended to explore such matters in the area of care-giving (which often touches the one cared for and the caregiver very personally). The book highlights the diverse priorities of doctors, nurses, social workers, hospital and nursing home administrators, insurance personnel and families, demonstrating how these differences act as major stressors in health care delivery (p. 5). Cultural divisions that are evident when one person's values are imposed on others (p. 9) and communication and exchange of information based on unexamined assumptions (p. 6) can add to the volatility of such situations. Like other culturally-specific manners of self-presentation, the extreme "professional role" of the professionals, policymakers, and administrators can act as a hindrance to proper communication and execution of care (p. 9).

Early on, the editors note that "The obligation of families to care for their ill and elderly members appears to be deep in every tradition, but the implementation may be difficult and unsupported because of contemporary circumstances" (p. 7). Professional training of health care professionals does not prepare them to go beyond their professional duties to comprehend the stress and limitations experienced by family caregivers (FCGs) (p. 11). In this age of globalization, significant portion of patient pools in the U.S. health care system consists of immigrants with widely varying cultural traits. Such differences can manifest themselves, for example, through the predominant role of women in caregiving, rules of behavior, and reciprocal obligations binding together members of close-knit families (pp. 59–62). Unfortunately, often there is a radical mismatch between the culture of medicine and cultures of families (p. 50). As a result, instead of working together the professional caregivers, FCGs, and the care recipients can become fragmented.

Levine and Murray's book demonstrates that health care system, like others in the U.S., reflects class divisions (pp. 41–2). Historically in the U.S., the rich and privileged could afford to pay for care from nurses in their homes, and trained nurses began to replace FCGs. The level of care and the duration of care depended on who had the money to pay for such services (pp. 70–1). Diseases that resisted other types of care, such as tuberculosis, were branded as the diseases of the poor and of immigrants, and poor people who suffered from them were often confined in jails and sanatoriums.

The authors recount how, in an attempt to mitigate the problems of social divisions, a deliberate shift was made to produce highly skilled nurses. However, they go on to show, that purpose was abandoned when efforts to make the health care system profitable were undertaken. Prior hospitalization became a requirement to qualify for home care (p. 75), for example. "In general, the barriers caregivers face reflect the policy culture's efforts to balance the desire to provide benefits with the desire to keep expenditures under control" (p. 108).

Family caregivers are outsiders in a hospital setting because of lack of professional training (p. 87). Ironically, the constant shifting of care for chronic illness means that FCGs today are taking more and more responsibilities. Regardless of how strongly the FCGs are portrayed in popular culture, they need assistance to prepare themselves to take up the role of primary caregiver for an ill or disabled family member (pp. 113–23). Often, it...