Long-term care, globalization, and justice by Lisa A. Eckenwiler (review)

The lament that health-care ethics focuses on individual and local relationships to the exclusion of the political dimension is familiar. Paul Farmer holds up an uncomfortable mirror to our field when he charges that we occupy ourselves with the "just allocation" of expensive health technologies—and do so without a sense of irony (Farmer 2004). Where we do address the political dimension of resource allocation—for example, Norman Daniels's work in the Rawlsian tradition—we stop at the borders of the nation state (Daniels 2007). If running a health-care system is the job of a nation-state (or some subnational unit), then what is there to say about moral obligations with regard to health and health care among states or across borders?

In this timely volume, Long-term Care, Globalization, and Justice, Lisa A.

Eckenwiler investigates a realm of health-care services (long-term care), a set of health professionals and paraprofessionals (nurses, personal-care workers), and a disavowed social and economic necessity (care work) at the broadest possible level of analysis, with particular attention to global migration of health-care workers. While she pays close attention to the structural level of analysis, Eckenwiler does not leave behind the core feminist insight that "the personal is political": she aspires to fashion and deploy an account of justice that is both structural and action-guiding for individual agents who care about building a just world, both global in its reach and particularist in its analysis. This is a tall order for a brief book (105 pages, not counting endnotes and bibliography). The book surveys interconnected ethical and policy issues and sketches the "ecological" stance she recommends we take up toward our responsibilities.

The first chapter describes the plight of the elderly and their caregivers in wealthy nations. Eckenwiler shows that demographic trends (an increasing proportion of the population is elderly), health trends (toward multiple chronic morbidity), and problems of quality of care in institutional long-term care—from coordination to human resources and training to fragmentation and privatization—result in a growing need for informal care giving for the elderly. How can governments resist exploiting the labor pool of the family to meet these challenges—where labor, as feminists have long pointed out, is neither remunerated nor accounted for in the national gross domestic product? Eckenwiler outlines the costs that governments and corporations do bear through mandated family leave, reimbursement for family care-giving expenses, and respite care, but these costs are minimal compared to that of a fully funded long-term care system. These informal caregivers, negotiating their burdens and seeking relief, in turn compete with health-care institutions and governments (and the low-wage service industries) for low-cost home-care workers, finding the needed human resources among those who, by identity (the "caring Caribbean nurse") or lack of citizenship rights (the temporary migrant worker earning a right to apply for full citizenship, the illegal migrant) are "suited" to devalued work. Meanwhile, informal caregivers are disadvantaged in their careers, lifetime economic achievement, and health by the "choices" they make to take time off, minimize work commitments, or retire early to care for family members—dynamics that are especially damaging for women and minorities.

The second chapter picks up the theme of the plight of paid care workers in wealthy nations. Personal-care workers, with a median wage in the United States only two-thirds of the median wage for the general population, may lack health insurance and other benefits, and even rely on food stamps. They are disproportionately women, racialized minorities, and legal and illegal immigrants. Nurses, by contrast members of a profession, may enjoy better pay, benefits, and job security than personal-care workers, but are increasingly drawn from a global labor pool of women in low- and middle-income countries via the ballooning private recruitment industry. Each of the prominent source countries (the Caribbean, India, the Philippines) has its own history of colonialism and globalization, leading by...