The Wages of Care: Change and Resistance in Support of Caregiving Work

Industrialized societies have done some things well. They increased the standard of living for large numbers of people, they opened up opportunities for knowledge not found in most agrarian cultures and they have advanced technology to the point where we can explore the solar system and transplant a human heart. This is not to argue that there are not major problems with the systems of distribution and the exploitation of the planet's environment, but by in large they have succeeded in increasing the production of the material basis of life. Where industrial and post-industrial societies have fallen woefully short is in the tending to social reproduction and personal care of human beings.

Until fairly recently many people assumed that the problems with the production, distribution and service of material goods were the legitimate interest of economics and government, and that the care of humans for each other was largely a personal matter. The problems in care, if they were addressed at all, were to be absorbed into the market, were the consequence of intrapsychic conflicts (Freud) or resulted from personal failing (family values moralists). The reality of the intensity of the work, its multifaceted nature, and the skills and supports needed to do even adequate care work have not been understood. There are many reasons for this, some of which we shall examine shortly, but the consequences of the lack of understanding have been seriously problematic.[1]

The world over the availability of day care is rarely adequate, elders and their children resist the institutional arrangements for care of people with frailty and people with disabilities and chronic illnesses are without adequate supports. The people who do the care work, usually women, are struggling to meet the demands of both work and caregiving,* yet they remain the least supported workers in the economy. This is as true for care workers like day care workers, private care attendants (PCAs) and nursing home staff as it is for unwaged caregivers in the informal sector.[2] Across post industrial economies there is great variety as to how care work is supported, but none have successfully brought human care work to a par with manufacturing and trade.

The United States is among the worst. While some parts of the population suffer from unemployment other parts suffer from too much work and many of them are caregivers. Overwork, with the occasional exception of analysts like Julie Schor[3] merits precious little attention and the poverty and income losses for care workers receive even less. In their old age "millions of today's working women will become destitute. They have done everything that our families and our society have asked of them only to discover that the nation's retirement system . . . actually penalizes them for serving as the nations caregivers.[4] Overwork and underpay have serious implications for a reduced quality of life for both the cared for as well as the care workers.

All of us need intensive care work for a prolonged period when we enter life and most of us need it at a number of other points before we leave it. It is paradoxical that this work is treated as marginal to the "real" work of society. Why are unwaged care givers so poorly protected relative to other workers in the U.S.? Why are women receiving Transitional Assistance to Need Families (TANF) being forced into the formal labor market with no attention to the work they are already performing? Why do so many women work in the market sector and then provide unpaid care work at home?

The Current Dilemma

As large numbers of women have become more engaged in market labor in the latter half of the 20th century and the beginning of the 21st many of them have learned what most women of color and women who were poor learned long ago — market work does not cause the work at home to disappear. The belief of some feminists that household labor would shrink to proportions of minor consequence were founded on the erroneous assumption that housework was the essential labor done in the domestic sector. Ann Oakley broke new ground in 1974 with her important book The Sociology of Housework. As useful as it was, it failed to clarify the critical fact that the care of human beings was what drove household labor, not housework. We could easily afford to transfer housework to the market, but transferring human care was another matter. Economics of scale that work well to mass produce shoes are disastrous when it comes to human care. Small numbers of caregivers, low turnover and time for interpersonal engagement are qualities that are essential for decent care. They are mostly irrelevant when making shoes. Yet, when day care centers for children, or nursing homes and assisted living centers have developed in the wage sector economies of scale have been among their chief attributes. The workers who staff the center are among the most poorly paid, with few if any benefits, no career ladders and minimal training opportunities. Not surprisingly, this has led to high staff turnover, and frequently, poor quality care work. The public with the resources to do so has resisted the model of care. When possible people have chosen to utilize family care providers or home health care workers. These workers are even more poorly paid with even fewer benefits than those in the public sector. Still others leave waged jobs to care for their children or parents with no wages or benefits at all.[5] The women and men who choose to provide personal care in our society do so at high economic and social costs to themselves, but market options are often too expensive, of too poor quality, or too poor a fit for the human spirit.

Is There A Revolution Coming?

When I wrote about caregiving in the mid 1980's[6] there was almost no discussion in academic or advocacy circles to draw from. Selma James was organizing "Wages for Housework" which captured little of the public imagination. (Today in organizing care workers in Bolivia she calls care work "emotional housekeeping.)"[7] Twenty years later there is a quiet revolution taking place, that is quickly getting louder. Books and articles on the work of unpaid care are receiving popular and academic attention.[8] Caregiving organizations such as The Family Caregiver Alliance, Citizens for Long Term Care and the National Alliance for Caregiving are publishing policy briefs and critical national studies. Advocacy groups like Mothers and More are growing. Mothers and More have 7,500 members nation wide and have "launched a campaign to get mothers, policy makers, employers and society at large to review unpaid care-giving as comparable to paid work."[9] The National Organization for Women (NOW) passed a resolution in 2005 for Mothers and Caregiver Rights.[10]

Perhaps the most momentous development is that major unions have been successfully organizing care work in public places and in individual homes. AFSCME, (The American Federation of State, County and Municipal Employees), has organized tens of thousands of day care workers across the country while its rival SEIU, Service Employees International Union, has had unprecedented victories in organizing home care workers in Illinois, California and Oregon. In 1999, 75,000 Los Angeles home care workers voted to join SEIU which was called the "biggest organizing victory since 1932."[11] In December 2005 SEIU negotiated a contract with the State of Illinois that will give in-home child care providers a 35 percent raise over a three year period and health care benefits. "Home care workers went from being an invisible work force to one of the most vibrant sectors in the labor movement, defending public benefits for the poor elderly and disabled.[12] In California AFSCME and SEIU have recently started a joint affiliation to unite homecare workers in a partnership called California United Homecare Workers or LCUHW which will represent 30,000 homecare workers in 25 countries.[13] (The 434 Bee p.2)

As one home care worker states: Twenty years of being unrecognized, underpaid, with no benefits, essentially an invisible workforce has made many of us frustrated and searching for solutions. I honestly feel the union is the only way homecare workers and our clients have the ability to be visible, to have a voice decision makers will hear and to press for improvements in the quality of care and working conditions.[14]

The workers who are being organized were traditionally ignored by unions, in part because of the invisibility of their work, and, in part, because of the logistical challenges individual workers in individual households posed. Homecare and family day care workers must be approached on a door to door basis. The workers themselves have been considered self employed even though most of the funds have come from a complex combination of state and federal funding. The process of establishing an employer of record, which was necessary for the legal authority to unionize, has been long and difficult, but the detailed union work and pressure of the workers themselves have led to victories in the face of long odds.

These organizational victories combined with increasing calls for national public policies to address care work may be the early rumbles of a seismic shift in the way we perceive and provide for caregiving work — or they may not. "Homecare workers are predominantly women of color and recent immigrants who have long been among the lowest paid in the United States,"[15] but Crittendon's book The Price of Motherhood made best seller lists by appealing to middle class and professional women. On the one hand, this is good news as women are raising their voices about the value of carework across class lines. It remains to be seen, however, if class divisions will be used to split growing demands into different camps. The resistance to recognizing care work as central human work has many intertwining roots. They go deep in our culture. It is worth looking at the resistance as we work on building change.

Invisibility

The invisibility of women's work in the home has been described by numerous analysts. Ann Oakley broke new ground in this area in 1974 and many others have followed her.[16] Historians have linked the invisibility of care work to the rise of industrialization and waged labor when the production of material goods moved from the home to the factory. Work became associated with what received a wage, and nonwaged activities gradually became non work. In the 1800s as the combined churnings of capitalism and industrialization subjected numbers of men to harsh and inhumane working conditions, home became idealized as a refuge, a place that could cushion the harshness of the market. For many men it became a place of relaxation and restoration. It also became a place for them where meals just happened, where clothing reappeared clean, where child simply grew from one day to the next, because the labor that went into producing those results was no longer done in their presence. Thus, by the 1930s when Social Security enacted protections for primarily white male wage earners, the only previous protection for caregivers, Mother Pensions, would be dropped as "misconstruction." They are not primarily aids to mothers but defense for children.[17] Aid to Dependent Children did not provide a dime for the mother or caregiver. Under Old Age Assistance an elder could receive up to maximum of $30 a month, while a woman raising a child could receive a maximum of $18 a month. From that time to this there have been various expectations that mothers getting public aid work for wages as the care work they were providing at home was not seen as "real" work.[18] This view of care work was also held by many of feminists who advocated for women to achieve equality with men through paid labor in the market, only to find once there, that many women were now doing a double shift. It has prompted some of the backlash against feminism currently being promoted in some circles.

Care Work as Love, Duty, or Nature

Invisibility has not only contributed to ignoring the labor involved but demeaned its complexity. (See Suzanne Gordon, for a thoughtful discussion of this.)[19] As the labor involved in care work became less visible, women, whether raising children or tending frail elders or the dying were understood to be doing it as expressions of love, natural bonds or filial duty. A particularly ripe example will illustrate the point:

A mother's love is part of the mechanism of the soul, and it receives no abridgement from that condition . . . We know it to be imperishable because it bears the impress of underlying perfection and it is cherished as life's chiefest beatitude wielding umpire over the domain of human tendencies.[20]

While care work does not require love, it does involve attentiveness and responsiveness to the spirit and sensibilities of the other. Consider the effect the attentiveness and skill makes in the following account of a day care teacher:

One morning Maria's mother said that Maria was going to another child's house that afternoon . . . I could tell she (Maria) was really upset about it . . . I had some rice and was serving it out for the kids, and she tipped the bowl and the rice spilled all over the floor. Instead of yelling at her I asked if she was worried about going to Jane's house. She burst out crying! She said, " I don't know what Sara's house looks like."

So we sat down . . . and we talked about it. I said if she were feeling worried during the day that tipping the rice over made it harder because then it made me angry, and she didn't get to talk about being worried. And she did a couple of times that day and it made me feel fantastic . . . That's what makes me feel good about being a teacher.[21]

When caregiving is described as a natural outgrowth of love it is frequently a dismissal of the complexity involved in care work, but it can also be a recognition of the importance of feeling. It recognizes that when we are ill we want more than clean sheets and medicines for our fever. We want human empathy for what we are enduring, and tenderness for our pain. One of the unspoken worries about acknowledging care work as labor rather than a natural outpouring of affection is the understanding that money can be traded for labor, but not for feeling. Thus, we worry that care work, like other aspects of human life under capitalism, will become commodified and we will be robbed of an essential aspect of our well being. "One of the main reasons that caring has been traditionally excluded from the market is that it is considered a moral responsibility rather than a calculated exchange."[22] Consider what is happening to care as cost containment measures are increasingly applied as care work that has moved into the public arena.

Deborah Stone writes:

Paradoxically, public accountability has brought moral confusion to the world of care. When people care in a public context as employees of any agency and, in effect, as agents of insurance companies or Medicare or Medicaid, they are made to feel that their personal relationships with clients are illegitimate — something to be hidden, kept in check, restrained, best left unspoken. Not only their professional judgment but their compassion comes under suspicion. They talk about caring and their caregiving work almost as if they were engaged in civil disobedience. They frequently justify themselves by using the terms "human," "friend," or "citizen" and insisting that the insurance or agency rules shouldn't prevent them from doing what any human being or any citizen would do.[23]

While care work cannot be reduced to expressions of love or duty, it is also diminished by the refusal to recognize the importance of relationship. There is an enormous literature in psychology on the importance to well being in humans of attachment.[24] Good care work takes a complex shifting interaction between physical and emotional labor. The need to be able to pay attention to both is what makes the work so demanding.

Gender Bias

One cannot pick up an article on care work in any form without substantive discussion about role of gender in the selection of the work. Care workers in all areas of human care, from birth to death, are overwhelmingly female the world over.[25] In the U.S. about 70 percent of caregivers are women.[26] Clearly there are many dedicated and excellent male care workers, but they are underrepresented in the arena of care work. Why this is so and what should be done about it is a matter of debate. For some, female care work is a natural outgrowth of the early mother infant care relationship. For others (usually feminists) there is nothing inevitable in the biology. It is a role that has been historically and socially reproduced and is consistently reinforced by a social construction of gender that shunts women in one direction and men in another.

Among feminists themselves, however, there are splits about the complexity of the work and its value. This is expressed in differences over whether or not women should push for care as central in human work, or leave it behind as low-skilled non-competitive work that distracts from women's abilities to compete in the market place.[27] None, however, deny that care workers are overwhelmingly female and that the workers are either unpaid or the lowest paid people in the developed countries. (An exception to this is child care in some counties where unionization and teaching standards have helped to produce better rates of pay for workers.)[28] There is also substantial awareness that the work, both paid and unpaid, is a major factor in the poverty of women relative to men. Some maintain that discrimination against women in the marketplace contributes to women crowding into female dominated jobs and that the crowding lowers the wages.[29] Recently a body of literature is emerging that shows that the complexity and social value of the work itself has been consistently underestimated and belittled in both the family and market sectors.[30]

As people actually examine the nature of the work it is consistently found to be more absorptive, more skilled, more complex and more demanding than had traditionally been thought to be the case. Still, some maintain that the work itself is essentially unskilled or at best low skilled, and thus in the logic of capitalism inherently low paid work. Still, others argue that not only are women discriminated against in the market, but the work they do is devalued. Studies are cited that show as women come to dominate a field the wages fall. (One earlier U.S. study ranked child care work beneath parking lot attendant and "well below dog trainer.")[31] Putting care work under a careful lens, however, reveals the attentiveness, anticipation, knowledge, timing, judgment, skills and social interrelationships involved in doing care work whether parent, PCA or care worker with elders. (For a particularly revealing examination see Danby's "Lupita's Dress."[32] It examines the work and executive skills entailed in the purchase of a dress for Lupita's daughter to attend her aunt's wedding.)

As the complex set of factors that go into basic care work become better articulated and more visible, it highlights the gender bias that has systematically robbed both the work and the workers of their critical role in society. But discrimination is not easily undone even when the injustices are clearly visible to the majority. The U.S. history of racism and its structural embededness are clear testimony to that. There is bias both against women and again care work. There is a serious wage gap between men and women. However, recent studies also show there is a wage gap between mothers and childless women. This is true even when education, experience, and length of employment are held constant.[33] These biases are interacting. Neither the gender bias nor the bias against recognizing the complexity of the work will be reduced without attention to both elements.

Care Work and Money

Free Riders

Most writers about care work repeatedly point to the disastrously low wages that market care work can command. The talented day care teacher cited earlier was thinking about leaving day care because of the low pay. She was considering becoming a bank teller.[34] In 1998 the Bureau of Labor Statistics found that day care teachers earned less than $15,000 a year and preschool teachers less than $17,000.[35] In 1999 according to the General Accounting Office elder caregivers (certified nursing assistants and home health aides) made between $15,000 and $16,000 a year.[36] There are a variety of economic explanations for the extremely low wages found in market care work (See England[37] for an overview), but the most obvious is the large number of women in the informal sector doing this work with no wages at all. As Paula England observes "We are used to getting it for free, so the attitude is why pay for it?"[38] Women who do this labor for their families without pay lose a lot more than a paycheck for the work. As Nancy Folbre and Ann Crittendon have pointed out in two compelling books on women and care work, for family care workers there is no unemployment insurance, no Workmen's Compensation and no retirement benefits to provide a safety net for their labor. But, these women who have typically been seen by economic analysts as "unproductive" are actually producing human capital.

In 1995, when the World Bank started to include estimates of human capital in measuring countries wealth the bank's first rough draft turned up the surprising finding that 59 percent of the wealth in developed countries is embodied in human and social capital . . . In the wealthiest countries human capital accounts for three quarters of the productive forms of wealth.[39]

Ann Crittendon goes on to point out that "If most of our national prosperity reflects the productivity of our human capital then the people who provide primary care to our children are the single most important source of our most important assets.[40] When seen in this light, it immediately becomes apparent that the costs of human and social reproduction are borne not by society as a whole, but by the women and men who do unremunerated or low waged care work. "In economics a "free rider" is someone who benefits from a good without contributing to its provision, in other words someone who gets something for nothing."[41] Because someone gets something for nothing does not mean that it is free. Someone pays the cost and in this case it is women as a class and care workers in general. Within the class of women, mothers earn less than non-mothers even when education, experience and skills are held constant.[42]

Recognition of the free rider effect of non-waged and low wage of care work has the potential for revolutionary impact, for if that work is compensated at anywhere near its value to society it will involve massive transfers of wealth from men to women, and from what is now deemed market profits to low waged workers. Such transfers will not happen without a fight.

The Root of All Evil

If the transfer of wealth involved were not enough of a barrier to adequately compensating care work there are also two other aspects of money and care that need to be considered. Many people fear that mixing money with care work will taint the essential qualities of care. It may seem strange to say in our money mad economy, but there is still a belief among people that "the love of money is the root of all evil." Consider the term filthy lucre. It implies that money is dirty and debasing. There is a puritanical strain that runs through many that mixing money and care will corrupt care. This generates an ambivalence on the part of many who, on the one hand, want to see care workers well paid and supported with an economic safety net, and on the other, fear the consequences. This ambivalence is reinforced by the legitimate fear of people with low and moderate incomes that if care work becomes well paid they will simply be priced out of the market when they need care. They are already witnessing the maldistribution of health care in the U.S. Of course, keeping the care unwaged in the informal sector or low waged in the market sector does nothing to insure quality, nor does it distribute it to those who may need it most, but it does insure that women who do the work will be vastly overrepresented among American poor.

Commodification

Regulation and commodification in health care is another source of reluctance to wage all care care work. In a capitalist society what is waged becomes a product to be weighed, measured, timed and regulated. But as I have argued elsewhere[43] the product assembly line model of industrial and post-industrial societies is antithetical to human care. Much of what makes for good care requires time, attentiveness and an understanding of the uniqueness of the other. Those qualities lead to trust and attachment which we call relationship. Who the caregivers are matters. As one analyst put it what the day care industry calls turnover, children experience as loss.[44] People who can get it want ongoing relationships with their care providers. Daughters and spouses care for ill or failing loved ones at great expense to themselves, not because they are unable to understand the price they will pay, but because they resist nursing homes where the staff turns over constantly (estimates range from 45 percent to 105 percent)[45] and relationships are considered a luxury not a necessity.

Where Does This Leave Care Work?

Moving care work into the mainstream of what we value as a culture will not be a simple or short challenge. As I have begun to outline, there are a number of powerfully entrenched interests arranged against it. But that does not mean there are not many policies and strategies that can push the current system and change its shape. There are many signs of change. One of the most hopeful pieces is that homecare workers and child care workers are coming together in unions. The disability community is uniting with PCA's to push for better pay and benefits. The constituencies for children, elders and people with disabilities, who have too often been competitors for money, are becoming allies and are pulling in the same direction. Ideas such as the Universal Caregiver Act[46] which unites services from the Older American Act and the Americans with Disabilities Act also seek to span disparate groups. There are a range of proposals for universal public supports for caregiving ranging from paid family leave[47] to providing Social Security credits and Workman's Compensation for unwaged caregivers. There are dozens of other proposals[48] and at least one clarion call for a national caregivers movement.[49]

To be valued for its real worth care work must be visible. When visible it must be correctly named as work and the importance of relationship must be included in the definition of the work. We must develop models of paid care that do not commodify it. The injustices of the poverty of care workers must be articulated and the free rider effect of our system of profits must be exposed. We must insist on the same protections for care workers as other workers in our society. We must reach across generations and identity populations to see how care work both shapes our lives and is shaped by them.

These are tall orders. To a large extent our goals will shape our strategies. If we want both men and women to do care work we will need shorter work days as well as a strong wages. If we want to support work in the informal sector then unpaid care workers need care worker wages, Social Security benefits, respite care and connections with care workers. If we want choice for people at different points in their lives then we need all of the above and more too. At the very least, we need an aggressive campaign to unite workers, to wage the struggle for better wages and to bring the work dignity and respect it so richly deserves. We all have an interest in this struggle because it is work all of us need to survive.