May 2003, Vol. 126, No.5
Security for care workers
Book reviews from past issues
Security for care workers
Care Work: The Quest for Security. By Mary Daly, ed. Geneva, International Labour Office, 2001, 261 pp., paperback.
A common theme of the essays composing this book is the decline in unpaid homecare rendered to the elderly, the disabled, and to young children—rendered almost invariably by women. It is a decline in the "gift relationship," as Richard Titmuss, one of the foremost British analysts of the welfare state, termed it. The essays discuss the reasons for the decline, and agree that this relationship is unlikely to be restored in modern society. Its place has been increasingly taken by paid care workers, whose assignments to care receivers are mediated by nonprofit organizations or for-profit firms. In addition, their expenses are defrayed by social insurance, social assistance, or other public or private agency.
The essays cover care in the advanced industrial countries and in a few developing ones. A key argument that has evidently spurred the publication of the book is that care, having the status of "decent work," becomes the subject of economic analysis (even when not compensated)—matters for which the essays’ authors insistently call. In the context of recent ILO programs, decent work is defined as, first of all, "security" that encompasses stable jobs; skills and abilities that can be used productively; an adequate income, including provisions for old age and disability; and health insurance. Care workers hardly enjoy any such security, as it is not mentioned by any of the authors.
Thus, Nancy Folbre in "Accounting for care in the United States" analyzes the prevalence of women in the care industries generally (health, educational, and social services), but she has nothing to say about their security (as defined). She reports that in many cases, "Bedside nurses have been replaced by unlicensed care ‘technicians’," that "…reimbursements to home health care workers have been cut back." In addition, managerial scrutiny has been ratcheted up, which, together with financial tightening, contribute to the (deteriorating) "moral world of care giving—impinging on quality and quantity." Developments such as these run very much counter to the "decent work" idea propagated by ILO and one of its senior program directors, Guy Standing, a contributor to this book.
Standing and Mary Daly also emphasize the idea of "occupation," as against "job" or "labor." They write that "care work is intrinsically a social relationship, in which moral sentiments, such as affection, altruism, mutual respect and dignity and deeply meaningful reciprocities come into play." Standing and Daly ask a commitment difficult to carry out in an environment of "marketization" and bureaucratization of care, such as outlined by Folber, and the near absence of a collective to help sustain such a commitment. The book’s contributors frequently complain about the loosening of solidaristic provision and the "cancerousness of individualism" of which R.N. Bellah has written, and which a highly commercialized society promotes.
It is true that the decline in unpaid care, hence of the gift relationship it implies, spells a shrinking moral space within which it occurs. But a premise of unpaid care work was the male breadwinner model of the welfare state as it was conceived during much of the 20th century, a "model" that held during the preceding period as well. But it has been eroded over the past 20-30 years by the rising labor force participation of women, discussed in some detail in the book. As a proportion of the working-age population (aged 15-64), women’s labor force participation rose to 71 percent in 1994 from 43 percent in 1960 in the United States; to 62 percent from 49 percent in Germany; to 62 percent from 46 percent in the United Kingdom; and to 74 percent from 50 percent in Sweden.
Jane Lewis, author of one of the most thoughtful essays in the book, cites literature holding that women’s rising earning power disrupts "the balance in the gendered division of labor and … [threatens] the stability of the family." Instability of the family arising from women’s earning power is likely to be mitigated, however, by the relatively high incidence of part-time work performed by women (27 percent of all employed women in the United States in 1995; 44 percent in the United Kingdom; 40 percent in Sweden). Family stability has no doubt also been affected historically by women’s attainment of property and political rights on par with men, and it also requires needed mutual adjustments between the genders.
A factor that induced women to join the labor force has been their ability to space pregnancies as new birth control technologies became available. Citing Richard Titmuss, Lewis writes that the average working-class British woman, marrying in the 1890s, spent 15 years in pregnancy and nursing, compared with 4 years spent by her counterpart after World War II. However this development may affect, or may have affected, family stability, it surely enlarged women’s personal freedom.
The erosion of the male breadwinner model, however, also entailed growing social and economic pressures on women to work. Unfortunately, the widespread need of women to contribute to family income by their earnings is not discussed in the book. There is mention, however, of the emergence of the "adult worker model" during the 1980s, by which it became a citizen obligation to work for pay (and which legitimized welfare-to-work rules and subsequent reforms). These changes raised, and continue to raise, urgent questions of childcare. "The obligation to engage in paid work" was argued in an environment that equally emphasized "the obligation to care."
European welfare states go far in helping women and men to meet this obligation. Public financing for childcare is "high" in 12 of the 17 countries listed in Mary Daly’s essay, for children 3-6 years old. It is "low" to "medium" for children up to 3 years old in most of these countries. All offer parental leave paid in full, although the number of paid weeks varies.
Public financing for the care of the elderly is medium or high—these terms denote relative levels of generosity—in 10 of 16 countries listed; the share of elderly receiving home services is medium or high in 12 of these countries; and the share receiving institutional care is medium to high in 8 of the 16 countries.
As Daly notes, the relative generosity reflected in the classification of child and elderly care is "intimately related to the prevailing ideology surrounding the family" in the countries listed. In the Nordic countries, child and elderly care is a right of social citizenship, but in European continental countries, care is to be provided in the first instance by the family. In Greece, Portugal, and Spain, care is more or less left to the family. Elderly care in the United Kingdom is classified as "high" not least because "the ideology of family solidarity, especially as it pertains to intergenerational relations among adults, is weak." Thus, resources otherwise (or elsewhere) provided by family may be required.
Among the advanced industrial countries, the United States is an "outlier" in terms of the sparse public support for the care of dependents, writes Nancy Folbre. For example, parental leave is unpaid, and restricted to employers with 50 or more workers. States have indeed raised their spending on childcare 50 percent since welfare reform in 1996, but only 15 percent of eligible families receive it. Vouchers have been widely distributed but at dollar levels too low for high-quality care. Tax exemptions and tax credits play a larger role in funding childcare (and other dependent care) but yield small or no benefits to families paying low or no taxes. Folbre is very much concerned with the inequities and distributional effects of government tax expenditures. For example, the exemption of employer-provided pensions costs the government an estimated $80 billion (in 1998)—a subsidy two-thirds of which benefit the top one-third of wage and salary earners; while Head Start, the early childhood education program for poorer children, costs $4 billion.
A section of the book is devoted to the representation, voice, and (to a lesser extent) working conditions of care givers. A chapter deals with the "carers’ movement" in England. Although it is concerned only with unpaid care givers for elderly and disabled younger persons dependent upon homecare, the movement is of considerable interest in that it gained voice and financial aid over the years under England’s National Health Service (NHS). It brought carers (most of whom were women) out of their isolation, and gradually gained visibility and a modest degree of political clout. This enabled them to persuade the NHS that by giving care at home, they saved it funds that otherwise would have had to be spent on institutional care, providing the rationale for the payments allowed them.
The isolation of paid homecare workers from one another; the lack of a regular employment relationship; the widespread practice of codifying them as "independent contractors" (or "independent practitioners"); and low wages have characterized the working conditions of these workers in the United States as "some of the worst … to be found across formal sector employment." Jess Walsh focuses on the Service Employees International Union’s (SEIU) efforts, centered in the Los Angeles area, which proved ultimately successful. After years of campaigning, the union finally organized 74,000 homecare workers by 1999. It overcame such problems (not usually faced by unions) as the absence of a common worksite and of a chain of employment responsibility. Care receivers retained the right to control how their care was to be organized; care workers had no right to a specific job but did have the right to work at any available worksite. The union got State legislators to set up public authorities under county supervision, resulting in representational and work security. The union also became involved in training its members for professional advancement in such fields as home healthcare and practical nursing, so they would have the prospect of escaping poverty.
Although limited in coverage, the volume presents a series of informative discussions, readily accessible to the reader, about a field of work and of care that needs more searching analysis and attention.
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