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Reviews / Comptes Rendus
| Karen R. Grant, Carol Amaratunga, Pat Armstrong, Madeline Boscoe, Ann Pederson, and Kay Willson, eds., Caring For/Caring About: Women, Home Care and Unpaid Caregiving (Aurora, ON: Garamond Press 2004)
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| THIS IS a timely book, given the rapidly changing context for home care in Canada, and the lack of debate or transparency about government reforms occurring in this area of public policy that touches us all. Over the years, with no national standards for home care, the provinces have evolved a patchwork of voluntary, public, and commercial services to address the needs of Canadians requiring this type of care, the majority of whom are the elderly and the disabled. Yet, despite admonishments from politicians to the contrary, the bulk of responsibility for providing home care still rests with families, a situation that has not changed for over a century. Currently, a combination of economic restructuring and an aging population is putting mounting pressure on families and communities to fill a gap created by diminishing provincial health budgets. Tensions are growing as governments redirect services towards acute care patients, and away from supporting the elderly and the disabled. In effect, an increasing number of us are being conscripted into providing care for relatives and friends, without being given the opportunity to debate the pros and cons of this shift in policy. The authors in this volume alert us to the fact that few Canadians have the necessary supports in place to fulfill this role without sacrificing their own health and long-term financial security. As well, it should come as no surprise that much of the writing in this collection examines the effects on women, who hold most of the paid jobs in this sector and are over-represented in the ranks of unpaid caregivers. Women also predominate as recipients of home care services. |
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In the name of neo-liberal ideology and fiscal restraint, the entitlement to home care is currently being rationed in a bid to curtail spiraling health care costs. The availability of new drugs and technology, and the shortage of beds, are used to justify the growing practice of rapidly discharging patients from hospitals. Contrary to myths that persist about the quality of life in rural communities, patients living in urban centres are more likely to have relatives and friends living with or near them who can be pressed into the complex and skilled role of caregiver. Many others must manage their care on their own, and the assistance they need is no longer provided in public health facilities. This trend raises the concern that the caring work taking place in homes remains largely invisible, and the writers give a detailed account of how this shift from public to private setting can bring many risks and challenges for both the care recipient and the caregiver. It can have detrimental effects on their relationship, on their long-term health and well-being, and on the quality of care provided. |
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These essays give us ample evidence of the value of home and community-based care, as well as pointing out the risks created in the current policy context, where home care is held up as a panacea for our troubled public health care system, yet the necessary supports to care-givers and care recipients are not forthcoming. Community-based services are one of the casualties of privatization and the incursion of the market system, and unpaid caregivers are becoming a substitute for a system under stress. The trend towards diminishing and "rationalizing" services is taking a high toll on various segments of the population, especially those for whom accessing services is difficult, including residents of rural and remote communities, Aboriginal Canadians, and Canadians with disabilities. |
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In the face of this swing towards neo-conservative reforms, the writers in this volume challenge us to think of home care as a public rather than a private responsibility. Rather than understanding it as an individual relationship between a caregiver and a care recipient, they encourage us to understand it as a collective responsibility. The authors challenge advocates and policy makers to envisage a national system that recognizes the rights, needs, and aspirations of those who receive care as well as those who provide it. Both research and practice show that an integrated and comprehensive community-care model works best and is also a cost-saver, as well as coming closest to the goal of respecting the autonomy and independence of both patient and care-giver. This volume contains examples of best practices, such as the Manitoba Continuing Care Program, which is useful information for policy activists and advocates. The Manitoba model erases the traditional boundaries between community, hospital, and home, and involves practitioners from a variety of disciplines in assessing and providing both short and long-term home care service, free of charge, based on need. It is a model that should be given more consideration by federal and provincial policy-makers. |
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The contributors to the volume are all members of the National Coordinating Group on Health Care Reform and Women, several of whom are involved directly in First Nations health, social, and economic development. The essays bring together an extensive body of knowledge about the home care needs of Canadians, as well as the demands put on those who provide this care. The volume also contains recommendations for building a Canadian home care system that is premised on universal entitlement, and goes far beyond the present targeted, means-tested programs. A theme that underlies all of the essays is the toll being taken on women by the current erosion of public home care services. The 2002 Romanow Commission on the Future of Health Care acknowledged that home care is becoming a burden on Canadians, especially on women. Many of the essays in this collection give evidence of the gendered nature of home care and unpaid caregiving, an aspect that is too often overlooked in much of the literature on the welfare state. In their bid to map out a blueprint for a system that does not reproduce inequalities, the authors deconstruct many of the assumptions and stereotypes that distort our assessment of policies and policy options. For example, we still hold an image of rural Canada as having extensive, close-knit communities. This stereotype is used to justify the redirecting of home care resources away from rural areas. In fact, women in rural Canada often take on the role of unpaid caregiver because of a lack of alternatives, including inadequate or non-existent services, poor public transportation, and the persistence of traditional expectations towards women. Another myth is that the majority of the elderly are reliant on the state for care; in fact, many elderly Canadians are providing care, thus relieving the state of this responsibility. The mantra we hear from government about the disappearance of 'our caring society' is also shown to be false; one in five unpaid caregivers in Canada are not blood relatives — they are neighbours or friends. Perhaps the most persistent myth is the notion that women have more time than men to devote to informal care. The male-breadwinner model of the family with women retreating from the workforce was short-lived and only predominant for a brief period following World War II. It was predicated on notions of family wages and a redistributive welfare state, neither of which exists today. Actually, women are more likely than men to leave the labour force to provide care because they are segregated into the lowest paying occupations and are over-represented in part-time and temporary work. Even though women provide most of the informal care to relatives and friends, few jobs allow them to take paid leave for this purpose, and three times as many women as men lose time at work due to caring responsibilities. Women's caregiving activities are directly linked to the growing phenomenon of non-standard, precarious jobs, where women are vastly over-represented. |
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As well, much evidence suggests that policy and legislation constructs women as caregivers. Thus, it is no surprise that in these neo-liberal times, women are being conscripted in large numbers into caregiving. In this volume, the authors challenge the assumptions that women have the skills, resources, time, and desire to providec are. They argue that caregiving is complex, skilled work, and our notion of who can provide care should be expanded to include those with no blood or marital ties. Regardless of who takes up this work, we must provide them with the necessary public supports to carry out this role. Finally, the authors caution us to be critical of policies that remove women from the workforce, even when accompanied by care-allowances. Women who drop out of the labour force run a high risk of finding themselves in poverty later in life, and also tend to become isolated from informal and formal networks of support. |
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Part of this collection is devoted to analysing policy recommendations. One theme that emerges clearly is that in the current climate of fiscal restraint, it will be an uphill battle to ensure that caring work is visible and valued. A meeting of health care advocates in Charlottetown in 2001 proposed a declaration of rights, calling for care to be made available to patients in a culturally appropriate and non-discriminatory form, and for the protection of the rights of both care recipients and care providers, to ensure that this relationship is a voluntary one. We need to be increasingly wary of neo-liberal governments who are expanding the definition of the family in order to force unwilling "volunteers" into a caregiver role. Perhaps due to the fact that this collection pulls together a number of essays from authors in the areas of health care reform and women, there is some repetition throughout. The introductory chapter, by Pat and Hugh Armstrong, provides a useful framework for scholars who are embarking on research in this relatively new field of inquiry. The index is a helpful guide to the many themes that are raised in the book, and for those who are researching a particular issue, will prove helpful in locating the material most relevant to their search. |
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Laurel Whitney
Simon Fraser University |
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