I argue that a particular epistemological approach, “ecological thinking,” helps to demonstrate that long-term care work is organized transnationally—through health, economic, labor, and immigration policies established primarily by governments, transnational corporations, other for-profit entities, and international lending bodies—to create and sustain injustice against the dependent elderly and those who care for them, and to weaken the care capacities of countries and their health systems, especially those of source countries. An ecological approach also helps to reveal the grounding of global responsibilities and an alternative conception of justice for long-term care and global health equity more generally.
Population aging is affecting all regions and most countries (WHO 2006a; Weinberger 2007). From 2000 to 2050, the world population aged sixty and above will more than triple from 600 million to 2 billion, moving from 9 percent to as much as 22 percent of the world’s population. Projections further suggest that elderly populations in many developing countries are growing more rapidly [End Page 1] than those in affluent ones. Compared to wealthier countries, low- and middle-income countries will undergo this demographic shift quite quickly, even as they continue to contend with the burden of diseases like HIV/AIDS and tuberculosis, and do so with considerably less in the way of resources, including human resources (Weinberger 2007; WHO 2002).
As governments face growing needs, and indeed, according to the Organisation for Economic Cooperation and Development (OECD hereafter), face “growing expectations” (emphasis mine) for quality, affordable long-term care services (OECD 2005, 10), a vision and strategic plan for long-term care is lacking. In many countries this has been a low priority and in others it is absent altogether from the agenda (WHO 2003). Long-term care in the United States, for example, is by all accounts “no longer viable” (Milleret al. 2008, 450). While there has been considerable debate concerning the nature and extent of future long-term care needs, especially given declining rates of disability in recent decades, the consensus is that these will grow (IOM 2008). The country, however, lacks a “comprehensive, coherent long-term care policy” (Levine et al. 2006, 305) and “an abiding social purpose that we as a society buy into collectively (Miller et al. 2008, 451).
Along with a host of other concerns, including financing and the fragmentation of care, long-term care experts in the United States cite building workforce capacity as the top priority. Nursing and direct care work (done by nurse aides, home-health aides, and personal-care assistants) are now characterized by unprecedented vacancies and turnover rates, with a declining number of people entering the field, retention problems, and a growing trend toward early retirement—especially in long-term care. The United States, many suggest, is facing a “care crisis” (Stone and Wiener 2001). Estimates are that between 3.8 million and 4.6 million nurses, nurse aides, home-health and personal-care workers will be needed by 2050 in order to meet the coming demand, a 100–140 percent increase over 2000 levels (DHHS HRSA 2004).
In this context, the employment—in some cases preceded by recruitment—of women from the global South for nursing and direct-care positions in hospital as well as long-term care settings is on the rise (Priester and Reinardy 2003; Chaguturu and Vallabhaneni 2005; Redfoot 2006). A growing number migrate from low-income countries with high disease burdens, more rapidly growing elderly populations, and fewer available resources to wealthier, healthier ones (Polsky et al. 2007; WHO 2006b). The United States stands out as the largest importer, and the only net receiver (Aiken 2007; Dumont and Zurn 2007; OECD [End Page 2] 2008). It is not alone, however, in embracing this strategy for addressing workforce shortages.
Absent is a rich examination of why current arrangements in long-term care are wrong and what should be the values on which future action is based. I argue here that a particular epistemological approach, “ecological thinking,” aids in understanding the global organization of long-term care work and its implications for justice. As Rachel Carson emphasizes species-interdependence and traces “patterns of chemical damage and natural fragility-vulnerability across a range of interrelated ecosystems” (Code 2006, 47), here I trace the dense—and increasingly transnational—connections that organize and constitute long-term care labor. Ecological thinking, more specifically, can guide such care planning by understanding and, in turn, ethically assessing the interdependence between policies (health, economic, labor, and immigration); places (long-term care settings in the global North and health-care settings in the global South, long-term care settings and workplaces, homes in the global North and South, transnational space); and people (the dependent elderly, paid care workers, family caregivers, and those who need care in source countries). I argue that an ecological approach helps to demonstrate that care work is currently organized transnationally—through health, economic, labor, and immigration policies established primarily by governments, transnational corporations, other for-profit entities, and international lending bodies—to create and sustain injustice against the dependent elderly and those who care for them, and to weaken the care capacities of countries and their health systems, especially those of source countries. It also helps to reveal the grounding of responsibilities and an alternative conception for justice in long-term care and global health equity more generally. But first, what do I mean by “ecological thinking”?
As typically understood, ecology describes “the study of patterns in nature, of how those patterns came to be, how they change in space in time, and why some are more fragile than others” (Kingsland 2005, 1). Ecosystem ecology involves “the study of ecological systems, and their relationship with each other and with their environment” (Pickett, Kolasa, and Jones 2007, 12). Ecosocial theories in epidemiology seek to integrate social and biological reasoning . . . to develop new insights into determinants of population distributions of disease and social inequalities in health, investigating who and what is responsible for population patterns of health, disease, and well-being, as manifested in present, past, and changing social inequalities in health (Krieger 2001). Philosophers who embrace ecological thinking explore the interrelationships between the environment, social [End Page 3] and political relations, “technoinformatic” structures, and our embodied subjectivity (Genosko 2009). The focus here is on how power relations and environments “constitute corporeality,” shape the way people exercise agency, and experience “lived spatiality.” How, they ask, do we as embodied, interdependent beings, constituted in part by social relations and structures, navigate particular terrains from day to day, survive, and even flourish? (Grosz 1995, 103).
The greatest inspiration for the work here comes from the work of Lorraine Code (2006). Ecological thinking, on her account, “proposes a way of engaging—if not all at once—with the implications of patterns, places, and the interconnections of lives and events in and across the human and nonhuman world” (4). An ecological analysis situates knowledge-generation, and in turn, policy-making, efforts in particular places, populated by particular people and conceived as intersecting “with other locations and their occupants” (21). “By tracing analogies and disanalogies from situation to situation” and by revealing the links between particular “ecosystems” (here long-term care settings in the affluent North and health-care settings in the global South, homes, workplaces, and “transnational space”), policies, and people, ecological thinking is concerned with “imagining, crafting, articulating, and endeavoring to enact principles of ideal cohabitation” (24). Stated differently, it aims to “discern conditions for mutually sustaining lives within a specific locality—be it an institution of knowledge production, an urban setting, a workplace, a geographical region, a community, society, state or the interrelations among them [emphasis mine]” (60–61).
Ecological thinking has four distinctive elements. First, the epistemological framework is critical of and aspires to replace reductionist models that “isolate parts of nature [and/or social life] so as to obscure the constitutive functions of multiple and complex interconnections” in generating effects (Code 2006, 42). Second, thinking ecologically situates knowing in specific locations, and highlights particularities and broad patterns among people and places. “[I]n its commitment to complexity, [this approach to knowing] urges attention to detail, to minutia, to what precisely—however apparently small—distinguishes this patient . . . from that, this practice, this locality from that, as Rachel Carson would distinguish this plant, this species, from that . . . all the while acknowledging and respecting their commonalities, where pertinent” (ibid., 280). Third, ecological thinking is attuned to power relations, situating its investigations “within wider patterns of power and privilege, oppression and victimization, scarcity and plenty” (280). Above all, it seeks to resist and replace “ecologically [End Page 4] uninformed policies of mastery that . . . filter evaluations of multiple forms of ‘damage’ through utilitarian assumptions about the end (= greater productivity, efficiency, and human comfort or safety), justifying the means (= the conquest of nature [human others],” and aims “[c]ritical-constructive analysis . . . at the entitlements and presumptions endorsed by governing conceptions of security and enhancement, at the evaluative ordering of species [and peoples] built into patterns of justifying these purposes, and at the overarching picture of the world—the dominant social imaginary—that holds this conceptual apparatus in place” (12). Finally, ecological thinking invokes a longer, temporal and spatial view, across terrains and time frames, and so allows for identifying effects and their sources that may not be readily apparent and for envisioning interventions that can be sustained over time. Rachel Carson’s critique of conventional studies on the effects of pesticides offers an instructive example.
My project here employs ecological epistemology in order to highlight the intersecting ethical concerns that arise for family caregivers in the United States struggling to meet the needs of loved ones in the face of a complex health-care system still not attuned to long-term care needs, as well as some of the world’s weakest workplace policies for family caregivers; migrant nurses and other care workers coming from so-called source countries in ever greater numbers to fill gaps in the long-term care workforce; and populations in these source countries suffering from health worker shortages. By invoking an ecological analysis and examining these groups and subjectivities in relationship, and as situated socially, economically, and geographically in “habitats” that are interconnected, we are better equipped to appreciate how the organization of long-term care work—rather, the absence of coherent domestic or global long-term care policy—stands to generate injustice against family caregivers, care workers, especially migrants, and to perpetuate health inequities among populations in poor source countries. With its conception of the subject in ecological terms, moreover, it helps to generate a conception of global health equity that is far richer than received accounts.
In the first part of the paper I move “transversely” across geographical and social, and economic and institutional “landscapes” (Code 2006, 7), drawing upon varied lines of evidence from different disciplines and topics salient to long-term care to explore the plight of the elderly and their caregivers, highlighting connections between particular policies and practices, people, and places. Next I examine the ethical implications of the existing structure of long-term care. Although we might describe the harm done in a number of ways, I propose that the best way of understanding it, as revealed by an ecological approach, is [End Page 5] in terms of structural injustice. In the third part of the paper I consider necessary criteria for an account of justice in long-term care. I argue for a conception that captures the structural nature of injustice, is global rather than statist in scope, and incorporates an ecological conception of persons. After identifying and examining “enabling” conceptions of justice, which emphasize capacities for self-development and self-determination, I propose an alternative aim for cosmopolitan egalitarianism in long-term care and health generally, namely, to equalize people’s capacities to become and to endure in cohabitation with others as ecological subjects. I also advocate a shift in focus from individuals as the principal targets of justice and, taking a page from the work of geographers, propose that we understand responsibility in long-term care, and perhaps global health equity more broadly, as a matter of “ethical place-making” (Raghuram, Madge, and Noxolo 2009).
Ecological thinking and the globalization of long-term care work
Around the world, family members are the primary providers of care, including for long-term care for the elderly (PAHO 2004; ILC-SCSHE Taskforce 2007). The work of these unpaid caregivers—the vast majority of whom are women—represents “a critical piece of the global health workforce” (Skjold 2007, 16; WHO 2006b). Yet those engaged in it face a set of norms, policies, and practices that make the work, and their lives, difficult.
As many governments restructure their roles to spend less on health and social needs under trends toward informalization and privatization, and healthcare institutions cut costs, family caregivers must contribute additional energy and resources. In the past decade, for example, efforts to contain explosive health-care costs in the United States have included shortened stays in hospital settings and early discharge of patients, a strategy whose success hinges upon the availability of family members to be home-care providers in what has been described as a sort of “semi-voluntary conscription of unpaid [and untrained] health care workers” (Nelson 2002, 278; Wolff and Kasper 2006). At the same time, arguing on the basis of cost-effectiveness and consumer self-determination, choice, and benefit, many governments have begun to restructure their roles in providing care and welfare services—especially home care and personal care assistance—and in the process, have shifted responsibilities onto family members (OECD 2005; Christopherson 2006; Ogden, Esim, and Grown 2006). [End Page 6]
Meanwhile, the caregivers working within families lack social standing and garner little respect in many countries. Their efforts are not typically seen as work, or in economic terms, as productive (Folbre 1999 and 2001). What this ignores, of course, is that “any person’s public existence floats upon the enormous amount of care work and reproductive labor that has come before and transformed a human infant into a capable citizen” (Tronto 2006, 4), or that is sustaining an aging person. Care, put differently, “is the deep and ignored background to citizenship” (4), and more broadly, to economic and social flourishing. Feminist economists and theorists of the gendered social relations of production argue that while this work is discounted by standard economic theories that exclude things produced in the household as opposed to the market, and that ignore the transfer of value from the household to the market, care labor makes a fundamental contribution or provides “input” into the processes of production. Yet societies are highly invested in the gendered and unequal division of such labor, for it leads to surpluses and savings in public expenditures (Badgett and Folbre 1999). Those who have tried to attach a dollar figure suggest that in the United States alone, the estimated worth of care work is somewhere over $375 billion, and is on the rise (Arno 2006).
Labor policies and workplace practices also challenge family caregivers. In a significant shift from what took place in earlier eras, the majority—more than half—of family caregivers in the United States and other high-income countries are employed in the paid labor force (Johnson and Wiener 2006; WHO 2003). But for the most part their employers offer scant support. The United States, in particular, is distinctive in having some of the weakest family leave policies in the world (Heyman, Earle, and Hayes 2007; Pavalko, Henderson, and Cott 2008).
As affluent women’s opportunities for work in the paid labor force expand and support for family caregivers remains scarce, opportunities for other women, increasingly migrants, to provide care for pay emerge (Kofman 2007; Bettio, Simonazzi, and Villa 2006). While paid care work has long been done by women of color, the modern commodification of care work tends now to take a transnational form (Bosniak 2009; Parrenas 2001a). What we see now in long-term care is a “contemporary expression of historically established arrangements . . . facilitated by advances in information and communication technology and shaped by contemporary organizational forms and dynamics of contemporary capitalist production” (Yeates 2009, 26). “Cheap and flexible, this model is [embraced] to overcome the structural deficiencies of public family care [End Page 7] provision and strikes a good balance between the conflicting needs of publicly supporting care of the elderly and controlling public expenditure” in privileged parts of the world (Bettio, Simonazzi, and Villa 2006, 282).
Social and economic norms around family care work and the frailty of family leave policy are only part of what shapes the increasingly transnational organization of long-term care. Care workers who are educated and trained in destination countries and employed in long-term care face conditions that threaten them, the quality of care provided, and moreover, contribute to global migration. Nurses and especially direct-care workers (DCWs) cite underinvestment, staffing that is insufficient to support quality patient care, increasing hours, rotation between units, centralized decision making, inadequate opportunity for continuing education and professional development, and poor compensation and benefits (Berliner and Ginzberg 2002; Steinbrook 2002; IOM 2004). These problems are widespread but especially acute in long-term care, particularly for directcare workers. Such conditions are in no small part responsible for the severe care-worker shortage—or so called care crisis—facing the United States where nursing and direct-care work is characterized by unprecedented vacancies, turnover rates, and a growing trend toward early retirement. Women from the global South fill a rising number of these nursing and direct-care positions (Priester and Reinardy 2003; Chaguturu and Vallabhaneni 2005; Redfoot 2006). For long-term care, the main source countries are the Philippines, Jamaica, Haiti, India, and the United Kingdom (Martin et al. 2009; Redfoot and Houser 2005). While informal recruitment through social networks including family members, former colleagues, and others is common, the growing demand for care workers, especially nurses, has contributed to the rapid growth in recent years of a for-profit international recruitment industry involved in a range of activities related to recruitment, testing, credentialing, and immigration (Connell and Stilwell 2006; Pittman et al. 2007). With the aging population burgeoning, even though hospitals are main drivers, long-term care settings play important roles (Leutz 2007; Browne and Braun 2008). The size of the industry has surged, along with the number of countries in which recruiters operate, many of which have high burdens of disease and low nurse-to-population ratios.
Underdevelopment in the global South and the emergence of neo-liberal economic policies may be the greatest contributor to the modern-day movement of care workers around the world. With the aim of encouraging economic growth and promoting global economic integration and interdependence, international financial institutions, chiefly the World Bank and the International [End Page 8] Monetary Fund (IMF), under the influence of dominant countries such as the United States, have compelled countries in the global South to balance budgets and become more competitive players in the global marketplace. Their main tools have been structural adjustment policies, which have in many places led to reductions in employment, including health-sector employment (Buchan, Parkin, and Sochalski 2003; Mackintosh and Koivusalo 2005; Stilwell et al. 2004), and have caused many in the global South to seek work in richer nations for the sake of survival. Although many care workers emigrate for their own sake and that of their families given the economic conditions they confront, their governments are also dependent upon them for economic survival. Some, like the Philippines, have taken to recruiting their own citizens for care work abroad as part of their economic development plans (Lorenzo et al. 2007).
Finally, immigration policies figure into the structure of long-term care to the extent that selective immigration, especially for skilled workers, is a strategy increasingly used as an instrument of industrial policy under globalization (Buchan et al. 2003).
Meanwhile, industry organizations in the United States (including the American Hospital Association, the American Health Care Association, and the National Center for Assisted Living), who regard international recruitment as a way to keep hiring costs down and improve retention, are lobbying in the United States for an easing of immigration requirements in order to gain access to nurses and other care workers are industry organizations (for example, the American Hospital Association, American Health Care Association, National Center for Assisted Living) (Pittman et al. 2007).
What is the harm done?
When we invoke ecological thinking, and situate long-term care work in a global context and trace interconnections between policies, places, and people, we see the ways in which the configuration of political, economic, and other social and institutional structures that transcend national boundaries and organize long-term care labor, imperil the elderly, their families and paid caregivers, and those who care for them, and serve to deepen health disparities in less privileged parts of the world. By eroding conditions and capacities when it comes to care, especially in countries constituted to export care labor, over time this “apparatus” (Agamben 2009) operates to sustain and reproduce spaces of deprivation. It also shapes subjectivities. [End Page 9]
Even as many, maybe most, desire to provide assistance, there is good reason for concern about family caregivers. There is now abundant evidence to suggest that caregiving responsibilities—doled out and taken on the basis of gender norms and the social and institutional policies that exploit them—have profound effects on the “practical identities” of family caregivers (Nelson 2002). Caregiving contributes to feelings of isolation and being unvalued, and leads many women to defer or even abandon their goals (Levine 2008; ILC-SCSHE 2007; Goldsteen et al. 2007).
The global division of care labor is fueled not just by “the ideological construction of jobs and tasks in terms of notions of appropriate femininity” but also in terms of racial and cultural stereotypes (Mohanty 2003, 141). The construction of Filipinas, for instance, as caring, obedient, meticulous workers, “sacrificing heroines” (Schwenken 2008), of Caribbean women as naturally warm-hearted and joyful, or Indian women as having “natural capacities” as caregivers (Abraham 2004) serves the aims of governments, industry organizations, employers, recruiters, and even family caregivers in the North, yet perpetuates stereotypes and can constrain the imaginations and opportunities of women and girls (Brush and Vaspuram 2006; Rodriguez 2008). Roland Tolentino’s study of Filipinas’ “integration into the circuits of transnationalism” (1996, 49) through the trade in mail-order brides provides an interesting comparison. Both phenomena are “situated in the historical positioning of Filipina bodies into a transnational space inscribed in [gendered], colonial, militarist, and capitalist histories” (49) and involve their “packaging” and use as “a tool for (limited) economic empowerment” (53). With major capital at stake, governments in the global South have been “only too eager to provide this habitat [emphasis mine]” for producing these embodied subjectivities, assessed by cost-benefit analyses as valuable “goods” or “resources” for export (53).
Operating in synergy with gender and racial stereotypes are overlapping varieties of nationalist rhetoric that support neo-liberal economic policies. One variety is organized around specific conceptions of national community and serves to compel labor migrants to “govern” their conduct for the economic benefit of the state (Raghuram 2009, 29). Another emphasizes “the active citizen,” a “reconfigured political identity . . . whose aim is to maximize . . . quality of life . . . by being [an] active agent in the market” (Schild 2007, 181). Exalting capacities, even pressing expectations for choice and individual responsibility, these strategies target poor women in specific ways, “encouraging and cultivating . . . forms of subjectivity that are congruent with capitalism in its latest phase” (199). [End Page 10]
Along with their “seasoning”1 as care laborers, women engaged in care work, especially those who migrate, are subject to “flexibilization,” a “process of self-constitution that correlates with, arises from, and resembles a mode of social organization” (Fraser 2009, 129; Fussel 2000). Its central features are fluidity, provisionality, and a temporal horizon of not being long-term. This happens in a number of overlapping, interrelated ways.
Family caregivers are compelled to navigate the fragmentation of the health-care system, fill the care gap created by cost-cutting measures, and contend with the consequences of policy makers’ division of family and paid care (Levine 1998). Those in the paid labor force typically find themselves distracted and stressed. They often decrease their work hours and take unpaid leaves (Lilly, Laporte, and Coyte 2007; Metlife et al. 1999; Pavalko, Henderson, and Cott 2008). Given “the temporally rigid way in which . . . professional commitments are defined today” (Hernes 2006, 313), family caregivers employed in the paid labor force are expected to be ever flexible and contort themselves to make do. For migrant care laborers, transnational economic and other structures compel them to mobilize when most say they would rather work at home (Van Eyck 2004). Too, there is the rapid expansion of the informal or “gray” economy, and the tendency to define more and more jobs as temporary and unskilled under neo-liberal economic policies (Sassen 2002). This phenomenon is clearly common in care for the dependent elderly, especially at home. What is more, allegedly upward and indisputably outward mobility to care labor markets in the North may involve taking jobs below the education and skill level of care workers, a practice known as “down-skilling” (Alonso-Garbayo and Maben 2009; Raghuram and Kofman 2004). As migrant workers experience vertiginous upward and downward mobility to conform to labor markets, health-care resources go to waste.
The social and political status of migrant care workers is also at stake. Even though countries like the United States incentivize immigration for some skilled workers, including some categories of care workers, questions of immigration and citizenship are contested (Ball and Piper 2002; Barber 2009; Dauvergne 2009). Care workers often lack citizenship in the countries where they are employed and therefore have a limited set of political rights (Bosniak 2009; Ong 2009; Deeb-Sossa and Mendez 2008). Long-term care is provided in a context marked by neo-liberal economic policies, the de-nationalization of economies, and the re-nationalization of societies. Migrant women workers thus find themselves supporting the social and economic activities of the more privileged while [End Page 11] compromising their own political status and participation in their home countries (Parrenas 2001a; Sassen 2002).
Due to immigration and travel laws that control the entry and exit of some nationalities stringently, some care workers, moreover, are unable to travel home to visit (Schmalzbauer 2004). Many live in transnational families and engage in transnational care practices, or “extended family relations and obligations across space and time” (Baldock 2000, 221). Like other migrants who describe a feeling of “dislocation” (Parrenas 2001a; Van Eyck 2004), some migrant nurses describe the experience of “having a foot here, a foot there, and a foot nowhere” (DiCicco-Bloom 2004, 28). The harms done to persons as individuals can threaten relationships in that they can lead others to “reinterpret our social or moral standing . . . [and] compromise the interpersonal bonds we have with them” (Miller 2009, 513).
Finally, the health of care workers—paid and unpaid—is also threatened by current arrangements in long-term care. Family caregivers are at heightened risk for chronic and elevated stress, poor physical health, depression, and death (Emanuel et al. 2000; Vitaliano, Zhang, and Scanlan 2003; Metlife et al. 2010; Pinquart and Sorenson 2003; Schulz and Beach 1999; Cannuscio et al. 2002; Godfrey and Warshaw 2009; George 2007). Those paid to provide care, especially direct-care workers, report major physical and emotional strain and high stress which lead in many cases to injury and/or poor health, yet are often unaddressed given the absence for many of health-insurance coverage (PHI 2009). Undocumented, noncitizen care workers are especially vulnerable (Meghani and Eckenwiler 2009).
If we turn next to consider the implications of current arrangements on source countries, we see still more cause for ethical concern. For many source countries, the hope of government and other policy makers has been that remittances sent home by those working abroad will stimulate economic growth and development through investment and business opportunities, increased trade and other networks, and knowledge transfer. The countries hope for a reduction in poverty (Page and Plaza 2006). Remittances have grown steadily over the past decade, and have come to exceed the amount of official development aid, foreign and private investment, and market capital flowing into source countries (ibid.). The United States is currently the lead originator of remittances. While remittances indisputably channel billions of dollars in money and other goods, there is little consensus about the overall social and economic impact of migration on countries that export workers (281). [End Page 12]
There is, on the other hand, however, an overwhelming consensus that when health workers leave, the health of the population erodes (Chen et al. 2004; WHO 2006). According to the World Health Organization, fifty-seven countries are facing severe health worker shortages (WHO 2006a and 2006b), shortages that serve to exacerbate global health inequities. Health worker shortages worsen inequalities in infant, child, and maternal health, vaccine coverage, mental health care and capacity to respond to disease outbreaks and consequences of conflict. The loss of nurses and other care workers is especially troubling, for they are the “backbone” of primary care in developing countries (Lynch, Lethola, and Ford 2008). Given the integral role of these workers to provide long-term care, these shortages also clearly present dire prospects for the rapidly rising population of elderly people and others with chronic and potentially fatal conditions such as HIV/AIDS. Shortages in health personnel are said to be the most critical constraint in achieving the United Nations Millennium Development Goals and the WHO/UNAIDS 3 by 5 Initiative (Anand and Barnighausen 2004; Chen et al. 2004; ICN 2006). Pressing demands on under-resourced health-care services further weakened by health-sector reform and structural adjustment programs, and the unprecedented migration of care workers, are generating what is, indeed, a crisis of care. If we look at the health systems of the main source countries for the United States, we find in them eroding conditions, exacerbated by the transnational transfer of care labor.
Where governments subsidize higher education, investments made in care workers can be effectively lost when caregivers work abroad or develop skills not applicable to their countries’ needs and/or capacities. Recent evidence suggests, moreover, that the adverse effects of losing health workers are not likely compensated by remittances, for they do not contribute to the development of health systems or compensate for the economic losses of educated workers (OECD 2008).
At the same time, as in the global North, populations age, the public sector retreats, and cost-containment strategies dominate the health sector. In developing countries women are consequently taking on additional care responsibilities (Lopez-Ortega, Matarazzo, and Nigenda 2007; Ogden, Esim, and Grown 2006, 336; Makina 2009). Governments facing under-resourced health-care systems have coped by “downloading” the burden of caring for those living with HIV and AIDS and others with long-term care needs onto women in individual households, who often work without the benefit of formally organized healthcare services. Whether these women stay home or migrate, under-resourced [End Page 13] and eroding health-care systems serve to further threaten women from low-income countries and compromise the health of those in need of care.
Beyond threatening health and survival in source countries, in separating families, the transnational transfer of long-term care labor stands to erode the foundations of social life. Given that the care done within families generates public goods, exporting care labor exports a society’s capacities for social relations and reproduction. For it is not just women’s paid labor, but also their unpaid care labor that is transferred out of source countries (they leave to stand in for what was once the unpaid care labor of other, now more privileged women). Indeed, to the extent that those with more resources have greater capacities to care—now by importing it—and so, to produce and sustain more capable citizens, the outflow of caregivers may generate profound global inequalities in social and political capacity.
While more speculation is necessary, in the absence of comprehensive data we might also consider the implications for destination countries. Host countries such as the United States clearly benefit to the extent that they get relief, at least temporarily, from labor shortages. This translates into better population health, including for those in need of long-term care, than would be possible if the care gap were to remain unfilled. More profit may also be generated for the business sector to the extent that many family caregivers contribute to businesses’ bottom lines rather than spending their days engaged in “less productive” work. It is likely that this imported labor is cheaper, as many care workers, especially the less educated ones, earn less than U.S. citizens receive in pay and benefits. Host countries may also gain substantial savings from not investing in the education of caregivers or in the health and social services sector when workers are trained abroad. Proponents of international recruitment maintain that there are considerable domestic-training cost savings in filling vacant positions with internationally trained health workers, even after accounting for the costs of recruitment and additional training to meet registration standards (Pittman et al. 2007).
At the same time, there is a growing body of evidence that points to major losses to businesses under current “care regimes” (Ungerson 2004; Metlife et al. 2006). It is estimated that the total cost in lost productivity—from replacement costs, absenteeism, interruptions, etc.—to employers for all full-time employees with care giving responsibilities is more than $33.5 billion (Metlife et al. 2006). It also seems fair to guess that the heightened anxiety and stress of caregivers—paid and unpaid alike—are burdens on their families and, more broadly, on the social fabric. Moreover, the United States and other countries turning to care workers [End Page 14] educated and trained in the global South and, in turn, neglecting domestic investment in education and training, risk the erosion of the countries’ educational capacities and their own capacities to provide care for their populations over time.
What of the group we began with, the dependent elderly in high-income countries? We have come full circle: if they get care, it may very well be of poor quality despite the extraordinary efforts of and harm done to many individuals.
Long-term care and transnational justice
An overlapping consensus of moral reasons can be marshaled to argue that the current configuration of long-term care is unethical. We might say that it is wrong because it threatens the well-being or welfare of persons, or because it constrains their agency, and in particular, their autonomy. We could also express the wrong in terms of threats to human dignity and the ideal of equal moral worth. On a relational account of harm, it becomes clear that the threat accrues not merely to individuals but “by extension, [to] the equal moral standing of their families and communities” (Miller 2009, 512). We might also understand the wrongs here in terms of distributive injustice, or a failure to allocate human and other resources equitably (Lethbridge 2004; Mackintosh, Mensah, and Rowson 2006).
Each of these accounts captures important aspects of the harm done by the existing organization of long-term care labor. Having, however, approached the organization of long-term care by thinking ecologically, “traversing diverse terrains” and mapping relations between people, policies, and places, we are in a position to generate a better, and richer, account of the harms here. Ecological thinking traces the operations of structural injustice. Structural injustice “exists when social processes put large categories of persons under a systematic threat of domination or deprivation of the means to develop and exercise their capacities, at the same time as these processes enable others to dominate or have a wider range of opportunities for developing and exercising their capacities” (Young 2006, 114). The ethical concern is not merely that structures constrain. “Rather the injustice consists in the way they constrain and enable, and how they expand or contract . . . opportunities” (114).
While there are differences in how they experience it as individuals, the injustice people suffer is both positional and general. Additionally, there are asymmetries among people in their experience of structural injustice. The dependent elderly in the United States, for instance, are vulnerable yet far less so [End Page 15] than those in source countries with care-worker shortages. Family caregivers in the North struggle, but they are better situated than care workers who migrate and engage in transnational care practices. More-skilled workers are better off than less-skilled, and authorized are better situated than the unauthorized.
Understanding injustice as structural enables us to trace our relationships, and the nature of our relationships to others, even across what might seem from a particular (myopic? nationalistic?) perspective at a great distance. Still, the complexity of the relations and processes involved in structural injustice presents challenges when it comes to the work of attributing and assigning responsibilities. Given the way that structures operate, responsibility is diffused or dispersed. It can therefore be difficult if not impossible to identify a particular perpetrator (individual or corporate) to whom particular harms might be traced directly (Young 2006, 115). At the same time, adverse effects are not necessarily intended but occur rather “as a consequence of many individuals and institutions acting in pursuit of their particular goals and interests, within given institutional rules and accepted norms” (114). A third challenge of grounding responsibility for structural injustice comes from a specific “phenomenology of agency underl[ying the] common sense conception of responsibility . . . which gives experiential primacy to near effects rather than [evolving,] remote effects of action” (114). This is important ethically because when consequences or outcomes are generated by an (often wide) array of agents and unfold over time, our sense of agency diminishes. That is, we see it “as implicated to a much lesser extent” (Young 2004, 373–74).
Consider two examples that draw upon the earlier discussion. Joan Tronto has argued that the tendency among middle-class and more affluent families in the United States to understand caring in private terms, that is, as a matter involving the needs of their loved ones exclusively, can lead to moral hazards including social harm. “In a competitive society,” she observes, “what it means to care well for one’s own [family] is to make sure that they have a competitive edge against other [families]” (2006, 10). More-privileged people may not be concerned if the caring needs of those who provide them with services go unmet. Ultimately, those acting with what Tronto describes as “privileged irresponsibility” tend to “ignore the ways in which their own caring activities continue to perpetuate inequality” (13). A second example comes from postcolonial theorists who maintain that conversations on the topic of care-worker migration obscure the extent to which this migration draws upon the legacy of colonialism and in turn overlook “the interdependent relationships . . . established over centuries of co-production of medical care across different parts of the Empire” (Raghuram 2009, 30). We might [End Page 16] also consider the relationships of responsibility that obtain between international financial institutions whose “development” projects claim to generate benefits, not harms, for source countries, including their health-care systems, or between U.S.-based health and long-term care corporations who recruit abroad and patients in source countries. Ties are indirect. Harms tend not to be intentional, direct, or swiftly identifiable. Relationships, and, in turn, responsibilities, are hard to trace.
Transnational ties, transnational responsibilities
The pattern of framing conversations about long-term care policy in nationalist terms ignores the growing reliance on care labor from abroad and its implications, including those for migrant care workers and, most troubling, source countries’ care systems, health and filial. Against those who argue that principles of justice cannot apply globally, dense relations of interdependence that connect people transnationally can justify principles of justice that transcend the boundaries of states. There are several ways to think about these relations. According to O’Neill (2000), the scope of an agent’s moral obligation encompasses all those whom an agent’s particular activities assume, and so, is often global. Many of our actions, in other words, are shaped by and contribute to the operations of institutions that affect others outside our own borders, and their actions shape institutions that affect us. On Pogge’s view, by “shaping and enforcing the social conditions that foreseeably and avoidably cause the monumental suffering of global poverty, we are harming the global poor.” (2005, 33). Our connection is a matter of being “materially involved” in or “substantially contributing to” upholding the institutions responsible for injustice (Pagge 2004, 137). Iris Marion Young proposes a “social connection model of responsibility” where “[o]bligations of justice arise between [agents] by virtue of the social processes that connect them” (2006, 102). “All agents,” in other words, who contribute by their actions to the structural processes that produce injustice have responsibilities to work to remedy these injustices” (103). But while received accounts of global justice see it as being grounded in something like shared humanity, imaginative association, or participation in injustice, we are in a better position to highlight the nature of our connectedness with ecological epistemology.
Incorporated into ecological thinking is an embodied, temporally and spatially situated subject for whom “locatedness and interdependence are [End Page 17] integral to its possibilities.” We are, in other words, “made by and making [our] relations in reciprocity with other subjects and with . . . (multiple, diverse) locations” (Code 2006, 128). We are formed and reside in habitats characterized—indeed, defined—by interdependence.
Ecological subjects, first then, replace the conception of the person that emphasizes rationality, independence, and equality among persons and thus serve to render the body irrelevant and ignore relations of dependency, our temporal nature, and our particularities. Such an idealization of the person obscures the significance of the body in our experience and, at the same time, “a fundamental role of all societies [viz.] to provide the circumstances under which humans can be cared for and thrive, given their differing degrees of frailty and vulnerability” (Kittay 2002, 78).
Bodies and caring relations are not the whole story. Places have to meet certain conditions if ecological subjects are to survive, much less realize justice. Rosemarie Garland Thomson’s (2010) notion of the “misfit” helps to shed light on the idea. Our shared vulnerability is not, she argues, just in our embodiment and potential to suffer, but also is in the need for “fit” between our bodies and our environments. “Misfits” are those who are ensconced in environments that cannot sustain them, or when, as she puts it, “the world fails the flesh” (2010). Ecological subjects cannot survive or thrive in the absence of functioning, effective health systems, and care relations, and they may struggle to exist when environments are constituted to narrowly define their possibilities, constrain their abilities to meet their needs and the needs of their loved ones, or when they live separated from people and places to which they may be attached.
A third dimension of ecological subjectivity involves what geographers have called the “inter-subjectivity” of place. Seeing place in relational terms, that is, as inter-subjectively constructed, “highlights the multiplicity of locations as well as the variety of interactions between people who are located differently that go into making places” (Raghuram, Madge, and Noxolo 2009, 8). Just as the development of “global cities” has spawned “survival circuits” (Sassen 2002)2 and drained poor parts of the globe of their populations, the burgeoning need for long-term care workers in the United States and elsewhere is threatening the availability of care in low- and some middle-income countries, shaping and potentially eroding parts of the social and institutional landscape in particular ways in particular countries. This raises questions about responsibilities “for those relations with other parts of the world through which . . . identit[ies] are formed” (Massey 2004, 13). We are responsible perhaps not (merely) because of [End Page 18] our participation in processes that generate injustice, or what we have done, but also because of who and what we are as ecological subjects.
By being able to trace more precisely the connections between those who contribute to and suffer from injustice, we are also in a better position to assign responsibilities, whose nature and extent vary. “Differences in kind and degree” of responsibilities “correlate with an agent’s position within the structural processes” (Young 2006, 126) and we can add, the geography of long-term care and care-worker emigration. The questions for justice concern how we are connected, and what are our capacities.
Along with putting us in a better position to acknowledge and attend to interdependencies and particularities among people and places, and to further ground responsibilities for justice, an ecological notion of citizenship might enable some forms of political recognition more appropriate to a globalizing world. It could better accommodate the millions of people who think of themselves as hybrids or as having a cosmopolitan identity.
Equality of what?
Thus far I have argued that ecological thinking shows the need to see people as embodied and embedded, and places as relationally constituted, to understand justice in long-term care as structural and responsibilities as global. What should we aim for in addressing injustice in long-term care? Contemporary work on justice has shifted away from thinking strictly about what people have—and the distribution of resources—toward their capacities. That is, we are now considering what they can be and do (Sen and Nussbaum 1993; Young 2006). Both the capabilities approach of Sen and Nussbaum and the social connection theory of responsibility offered by Young are “enabling” conceptions of justice in that they aim at attending to the social and political conditions that support capacities for self-development and self-determination. According to a related view, of justice as “equal positive freedom,” justice requires more than “the absence of constraining conditions such as coercion and oppression” but also access to the means or conditions for “self-transformation” and the “development of capacities and the realization of projects over time.” Justice, here too, is about “the availability of enabling [emphasis mine] conditions” (Gould 2009, 165–66). Recent work on global health inequities has, in turn, embraced this emphasis on supporting individuals’ “beings and doings” through a concept of health capabilities (Ruger 2006).
The capabilities approach, however, has met with criticism for its universalism. Another line of concern applicable to all of the enabling conceptions of [End Page 19] justice involves their shared emphasis on the ideals of “self-development,” “self-determination,” and “self-transformation.” This heavy emphasis on individuals and their powers to choose, chart their paths, and transform themselves obscures the mutually constitutive, interdependent nature of persons and places. When it comes to the dependent elderly, it may even be a dangerous ideal at which to aim in long-term care policy, given social norms—and to some extent physical realities—that the elderly are in a state of ultimate cognitive and physical decline. It also may leave them vulnerable—especially in a context marked by cost-cutting—to some notion that they can be left to fend for themselves. In a culture marked by an emphasis on self-reliance, this seems especially likely. As for migrant care workers and source countries, this is the sort of discourse that has been used to shape them into the kinds of “developing,” “self-determining,” and “empowered” economic agents desired by the architects of the global economy (Schild 2007). All the players here are, indeed, vulnerable to the retraction of the public sector and a growing emphasis on individual responsibility for self-care.
The more open-ended notion of “human flourishing” is another proposal for the proper aim of cosmopolitan egalitarianism (Sypnowich 2005). While we cannot equalize flourishing itself, we can “target the unequal conditions that produce unequal flourishing” (73). This approach aspires to pay attention to “the particular context and subjective situations of the people involved” (73), yet understands the notion of “flourishing” as somehow transcending them. Arguments for justice in addressing global inequities, including global health inequities, hold up human flourishing and well-being—often used interchangeably—as the target. In proposing a moral framework to guide future progress toward the Millennium Development Goals, for example, Jeffrey Waage and his colleagues argue for a view of “development” “as a dynamic process involving sustainable and equitable access to improved well-being . . . that is, the freedom to enjoy various combinations of beings and doings . . . . [or] to make choices and act effectively” (Waage et al. 2010, 1009). Similarly, Jennifer Ruger’s inspiring work on global health argues that the wrongness of global inequities lies in their threats to human well-being and flourishing, defined as having overall capabilities to achieve a range of “beings and doings” (Ruger 2006).
When we delve deeper, though, we find that the suggested constituents of “flourishing” bear a striking resemblance to the usual suspects: “being able to choose how to live,” “self-mastery and objectively worthwhile pursuits” (Sypnowich 2005, 63), “to make choices and act,” or “to promote and achieve” (Waage et al. 2010, 1009). This account thus seems tainted by the same [End Page 20] individualistic, mastery-oriented, and universalizing tendencies criticized above. Moreover, when the goal is to help promote people’s capability to achieve alternative “beings and doings,” there is a tendency to overlook our temporal nature and the fact that our interactions and other processes are ongoing and opening into the future under ever-changing conditions. Finally, under current conditions it may be too ambitious and take too long to achieve. With survival at stake for some in source countries, and the burgeoning population of elderly in need of long-term care even in privileged places, we need a target that is attainable in the shorter term.
At the heart of what enabling conceptions of justice appreciate is a particular constellation of capacities: to be generative, creative, and to participate in shaping our trajectories as embodied, temporal, situated beings. If we jettison the excessive emphasis on “self” and shift our attention more in the direction to the idea that we are interdependent, indeed, ecological subjects, we might describe this in the language of “becoming” and “enduring” (Bergson 1911; Grosz 1999), that is, our capacity for becoming and duration. Becoming can be understood as having the capacity for emergence, evolution, and expansion. Duration, on the other hand, encompasses capacities for sustaining ongoing processes of “conservation, preservation, and abiding” (Casey 1999, 218). Decision, action, and mastery are not necessarily—though they could be—what gives life meaning. The concepts of becoming and duration leave open more possibilities. Both can only occur in concert with other ecological subjects. Both can be precarious if not impossible, depending upon how one is situated in social structures and particular locations.
With the capacities to “become” and “endure” as universal norms and robust egalitarian processes for making decisions about what precisely this demands in particular contexts for particular people, we can avoid being excessively individualistic and risking a kind of neocolonialism with a caring face. Instead, by dealing head-on with the fact that meanings and expressions of becoming and enduring, harming, and so on are situated socially and so constituted relationally, we pay careful attention to particularities of people and places. It also highlights our temporal nature.
Thinking ecologically, moreover, reveals the need to resist an excessive emphasis on individuals as the primary units of justice. Indeed, they cannot be lucidly conceived apart from their embeddedness and engagement in and movement through social (transnational) processes and spaces. The target of efforts aimed at justice, then, are the structural and social processes created and [End Page 21] sustained by governments, international financial institutions, transnational corporations, and so on, that create and sustain the kinds of conditions that diminish people’s potential to become and endure in and across particular places.
Justice, on this view, calls for not creating conditions of deprivation (which cannot support and sustain capacities for becoming and enduring); supporting conditions that facilitate and sustain becoming and duration; and promoting conditions for ending deprivation and facilitating becoming and duration. Justice cannot be realized on this view by refraining from interference or avoiding the imposition of “systems” or “orders” that prevent others from achieving opportunities. It can only be achieved through support of the conditions that make becoming and duration (and perhaps ideally, flourishing) possible in particular places. Responsibility, I want to argue, involves “ethical place-making” (Raghuram, Madge, and Noxolo 2009, 7). When it comes to global health generally and long-term care specifically, this calls for us to focus on the needs of countries, regions, communities, institutions, and households, and the interdependencies—past, present, and future—between and among them, aiming at equalizing the conditions for becoming and duration.
An approach to global, or cosmopolitan, justice for long-term care that focuses on sustaining places that support capacities for becoming and enduring strikes the right balance between acknowledging the past yet privileging the future. This would represent a major advance in global public-health policy and planning. As critics have observed with respect to public health generally (Graham 2010), and long-term care specifically (Miller, Booth, and Mor 2008; WHO 2006a), the future is strikingly absent from view.
As we strive to meet our obligations to the elderly in the United States, we must resist the sort of thinking that suggests we can continue to lurch forward by “promulgating solutions to discrete aspects of the problem[s]” (Miller et al. 2008, 451) and that sees long-term care policy as merely a matter of domestic (i.e., state and/or personal) concern. Ecological thinking has the potential to transform the way we approach long-term care, for it enables us to trace relationships among an array of policies and programs—promulgated by governments, the health-care industry, the for-profit sector, and international lending bodies—that generate and sustain patterns of injustice against the elderly and their care providers (paid and not) as well as populations in the global South, and create environments that are, if not uninhabitable, perilous. In turn, it helps in the [End Page 22] effort of grounding responsibility for justice transnationally and formulating a conception that is best suited to create more equitable “livable futures” (Rawlinson 2008) for ecological subjects wherever they are.
Lisa Eckenwiler is associate professor of philosophy in the department of philosophy and in the department of health administration and policy at George Mason University. She serves as the director of health care ethics at the Center for Health Policy Research and Ethics. She has published widely in bioethics and publichealth ethics. Her second book, Long-Term Care and Global Justice: Thinking Ecologically, will be published by The Johns Hopkins University Press in 2012 and she is co-editing a book with Zahra Meghani, Female Migrant Workers: Ethical and Political Issues, to be published by Routledge.
1. Here I draw from the concept as used by Marilyn Frye in her 1983 work, The Politics of Reality (Freedom, CA: Crossing Press).
2. Sassen (2002) uses the term to describe the migration abroad for work and the sending home of remittances to help sustain the economies of impoverished countries. “These survival circuits are often complex; multiple locations and sets of actors constitute increasingly far-reaching chains of traders and ‘workers’ ” (255–56). Further, “as the term circuits indicates, there is a degree of institutionalization in these dynamics; that is, they are not simply aggregates of individual actions” (265).