Elana D. Buch’s Inequalities of Aging: Paradoxes of Independence in American Home Care

Inequalities of Aging: Paradoxes of Independence In American Home Care

Elana D. Buch

New York University Press, 2018. 263 pages.

Elana Buch’s critical and thoughtful analysis of the American home care system highlights the ways in which older adults try to simultaneously maintain their independent identities and generate new relations with the home care workers who assist them with assigned tasks (page 2).  Buch traces the relations between care givers, their clients, and two home care agencies in Chicago (“Plusmore”, a public agency holding a contract with the State of Illinois, and “Belltower”, a private agency) to argue that these commingled lives, intersecting at the heart of inequality and aging, emphasize the vulnerabilities of both the elderly and home care workers.  Increasingly workers face low wages and poor working conditions, which impacts high worker turnover rates and subsequently lower quality of care for the elderly (page 6).  The lives of older adults and workers are entangled, connected by the stark lack of empathy that US society has for the caring profession and for the elderly (page 6).  Buch focuses on the moral demand for carers to set their own physical and emotional wellbeing aside in the care for their aging clients to expose the simultaneous independence and inequality that are created by the social relations between carers and the elderly (page 10). 

In particular, Buch analyzes the concept of generative labor, or the “…wide range of moral imaginings, practices, processes, and relations through which people work together to generate life in all its form” (page 6).  In doing so, she discusses care relationships in practice, or the historical and everyday processes that create home care relationships, and the meanings and consequences of those relationships for those who participate in them.  Generative care is built on reproductive labor, which raises new questions about conflating generative care with biological reproduction and which draws parallels between the assumptions that biological reproduction equals maternal care, and about the subsequently inequitable status of home care as a job (page 13).  Discussions of care often index Euro-American moral imaginings about the ways that the interdependencies necessary for generating life should be organized, such as who should care for whom, in what ways, for which reasons, and to what extent (page 16).  In the United States, independence is socially valued and is a defining moral criterion for personhood (page 19).  However, despite Americans’ emphasis on independent living, people of every age and ability profoundly rely on others.  Older adults’ independence comes into question not because they are more reliant on others than those of other ages, but because their interdependencies are more visible. 

Buch also delineates the ways in which home care agencies understand older adults’ independence, particularly in light of how home care workers’ very presence threatens to reveal elders’ diminishing ability to meet the demands of liberal personhood (page 21).  The relationship between home care workers and poverty is not coincidental: many workers found care jobs through welfare-to-work programs created by neoliberal welfare reform policy in the 1990s (discussed further in chapter 3).  Chicago’s home care services are bifurcated along economic lines: if older adults (or their kin) have sufficient income and assets to afford to hire workers themselves, they have a number of choices about how to organize this care.  In Chicago, older adults who have limited assets and income can receive services through the Illinois Community Care Program (CCP).  The CCP negotiates contracts with home care agencies to provide publicly funded services to older adults who qualify (page 26).  Older adults’ concerns about sustaining independence reflect the central role this value plays in dominant American conceptions of personhood, which Buch emphasizes as a culturally and historically variable category of membership in social worlds (page 34).  Throughout her book, Buch focuses on older adults’ struggle for physical and social independence in the face of weakening bodies and a rising need for help from others.  The role of the home care agency and workers in the lives of older adults is complex and fraught with tensions between older adults who want to maintain the appearance of independence, home care workers who care for the elderly despite low wages and poverty, and the home care agencies which must please their clients while simultaneously adhering to federal and state policies and earning enough money to remain afloat.

Buch organized the rest of her text into several thematic chapters revolving around the relations between home care workers, their clients, and the home care agency supervisors, all of whom have pressing concerns that often contradict the concerns of others involved in the triangle  (client, home care worker and agency) of care service.  Chapter 1 traces the histories of several of the elderly clients who receive care from one of the two agencies in Buch’s ethnography.  Buch also expands on the concept of independence as a valuable resource for older adults, many of whom need to share their time and personal space with near-strangers as they age and experience health crises that require them to concede their independence in the face of much-needed and constant care (page 36).  For example, Harriet Cole, a “Belltower” client, had a stroke yet was determined to remain independent, drawing on her life history as a Southern black woman growing up in the interwar years.  She grew up in a large family and cared for both her younger siblings and for elderly relatives, and was thus well-versed in the practice of caring for others (page 39).  She presented herself as the generous patron of Virginia Jackson, her home care worker, and compared Virginia to a domestic servant, which helped her maintain her identity as a middle-class woman despite bodily, domestic, financial, and social vulnerabilities she faced as she struggled to present an independent façade (pages 43-44).  Despite sharing the same ethnic background as Virginia, Mrs. Cole did not trust Virginia and preferred to treat her as a domestic servant in order to maximize her own independence and downplay her growing vulnerabilities (page 43).

Like Mrs. Cole, Hattie Meyers grew up a black woman in the South and was well-versed in professional care, and as such had high standards for her own home care worker.  She wanted a home care worker who would know what to do without needing to be constantly reminded, and while she knew that the worker who cared for her (Loretta Gordon) lived a troubled life, she wanted someone who would stay around for a while instead of constantly calling out sick.  Eventually, she settled for someone “good enough” rather than being a perfect fit, which also carried the benefit of Mrs. Meyers not needing to retrain new workers every few months (pages 59-60).  In general, Buch argues that the ways that people morally imagine both their own personhood and that of others are culturally and historically contingent, but also reflect their particular histories of experience.  Older adults’ life histories highlight the multiplicity of ways in which people come to understand the concepts of personhood and independence (page 61).  Like Mrs. Cole and Mrs. Meyers, who both grew up with particular histories and drew on their personal experiences in their interactions with their respective home care workers, the experiences of many older adults reflected their different racial, economic, and geographic locations (page 61).  The workforce for both agencies comprised primarily of women from low-income families of color.  These broader histories form the invisible foundation upon which Home Care Workers’ (HCWs) lives play out, shaping the possibilities and challenges that workers navigate as they try to make life possible for themselves and their kin (page 63).

In Chapter 2, Buch reviews the seemingly separate histories of US labor law, elder care policy, and anti-poverty programs to show the role of these programs in creating a home care.  She provides a brief history of the policies and social legacies that underlie engendered work and caregiving in the US, beginning with the Great Depression, when widespread unemployment and poverty left millions of people struggling to take care of their elderly kin, and desperate families increasingly left their kin at public hospitals (page 65).  The 1935 Works Progress Administration (WPA) introduced the first federally funded paid caregiving service, although the WPA was billed as an anti-poverty measure that would instill independence through labor, in order to dispel any misconception that direct income might inculcate dependence on federal funding.  Through the WPA, the Housekeeping Service reproduced existing hierarchies of gender, race, and class. The WPA only funded one job per household, which typically went to men in married couples; for this reason, most of the Housekeeping Service’s employees were divorcees and widows (page 66).  The Fair Labor Standards Act (FLSA) set a federal minimum wage, guaranteed overtime pay, and outlawed child labor in most occupations.   US Congress amended the FLSA in 1974, finally extending its protections to most domestic workers, although it continued to exclude “casual” babysitters and those providing “companionship” services to individuals unable to care for themselves due to age or infirmity (page 66). 

Programs targeting care for older adults are typically considered distinct from programs targeting poor children and families, yet aging policy and anti-poverty policies have complex, tangled effects on the lives of multigenerational families and the lives of care workers.  For example, the Aid to Dependent Children program (ADC), which was introduced in 1935, provided cash to poor single mothers raising minor children, but didn’t apply when an adult male was present, and it didn’t apply to black mothers, since it was expected that they would work regardless of marital status.  The ADC ended in 1996, when President Bill Clinton introduced the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, or “welfare reform”), which provided recipients with temporary financial assistance while requiring their participation in work programs.  The PRWORA provided funded job training and child care to support welfare-leavers, and focused on preparing women for low-wage jobs rather than supporting the higher education or advanced skill training for middle-class jobs (page 68).  Domestic work has long been thought of as a suitable labor for immigrant women and women of color because “workers were thought to benefit from the opportunity to be ‘modernized’” through their exposure to the daily lives of wealthier white households.  As a consequence, immigrant women, like US-born women of color, fill a disproportionate share of domestic and direct care jobs (pages 68-69).

From state-sanctioned slavery through welfare reform and the companionship exemption, federal law and public policy generate social conditions in which providing care for pay remains an important means of survival for women of color (page 69).  Welfare offices (and the politicians that wrote the laws those officers enforced) claimed that poor women would be better off building families according to white bourgeois kinship norms (page 72).  Furthermore, the white bourgeois kinship norms didn’t always apply to the diverse forms of kinship in which home care workers lived, particularly due to different cultural norms, poverty, low wages, lack of benefits, and other structural and cultural factors that contributed to various kinship living arrangements.  Home care worker Doris Robinson’s grandson Teshawn lived with her, and at eight months had yet to roll over.  She was concerned about developmental delays and had to make an appointment for him to be tested. Doris herself had dyslexia and had fallen through her school’s cracks as a child, and was well-versed in handling bureaucratic delays, endless forms, and fragmented social service systems that didn’t notice a child in need of help (page 62).  Doris was able to draw on her own experiences with undiagnosed childhood dyslexia to know what to do for her grandson; her practices, like so many other home care workers, are based in either personal experience or learned from a family member.  Doris learned about caring from taking care of various siblings and elderly kin when she herself was young, and taught her daughter Janice the same level of care, therein passing down the moral imaginings that are part and parcel of the profession of caring (page 77). 

Home care workers like Doris learned alongside kin the forms of generative labor required to sustain their families amid ongoing violence and hardship, as the policies create and perpetuate fragmented, underfunded systems of elder care that depend on poor women of color who have little option but to work for low wages (page 84).  Under current labor and welfare policies, women who worked in essential but underfunded fields like home care have little chance of ever earning enough to support their kin, thanks to long legacies of discrimination inscribed into social and economic policy (page 84).  HCWs described themselves as moral and practical authorities by virtue of their commitments to care.  In doing so, they continued a long tradition of domestic workers promoting the moral value of generative labor as a way of critiquing the low social and economic value attributed to this work.  A popular discourse in the United States often depicts care as a natural extension of women’s biological capacities for reproduction, and implicitly racist discourses paint women of color and immigrant women as naturally better caregivers – i.e., “closer to nature” (page 85).  Home care agencies rely on the generative labor of workers’ kin to lower costs and increase profitability in an intimate instantiation of capitalism’s broader dependence on kinship relations.  Home care agencies harness the models of kinship and care that home care workers learn from their families, turning workers’ inheritance into revenue (page 86).

Buch dedicates Chapter 3 to the training and supervision that home care workers receive from the home care agencies, and particularly to the tensions between the federal laws and policies governing professional care in the United States, the market-based platforms on which the agencies operate, and the moralities of (generative) care that underlie home care workers’ dedication to their clients (page 90).  In addition, publicly-funded agencies like “Plusmore” depend on fulfilling their contracts with the states in which they’re based (Illinois, in “Plusmore’s” case), although more and more publicly-funded agencies also work for government contractors, which complicates the jobs of supervisors who thus need to implement public policy while maximizing their employers’ revenues (page 91).  “Plusmore” had a detailed and standardized Determination of Need (DON) form used by case managers to assess whether the applicant has the requisite amount of unmet need for care to qualify for program services (page 101).  The DON is used to generate each client’s specific service plans, also called “care plans”.  Care plans typically list the activities for which the client has been authorized to receive assistance from a care worker.  The DON represents one way that public moral logics about fairness and equitable access to public resources remake older adults and their households in the context of home care services (page 104).  By enacting ideologies of individualism, the DON establishes the state as an ethical arbiter of resource distribution (page 105).  Family members are considered only to the extent that they make claims on assets or help older adults accomplish daily activities (page 105).  However, “Plusmore” clients frequently lived with family members, leaving supervisors to disentangle the generative labor required to sustain elders from that required to sustain their households.  Imagining elders as independent from their households was a useful fiction that made it possible for the state to fund care for vulnerable older adults without being accused of paying for poor families’ housekeepers (page 111).

On the other hand, private agencies like “Belltower” depend on customer satisfaction and word of mouth to stay in business, and supervisors simultaneously tried to satisfy customers while also adhering to a variety of legal and ethical demands (page 92).  The difference in funding sources affects how agencies imagine and generate their clients’ independence: at “Plusmore”, state procedures and laws emphasized the rational, equitable distribution of resources based on an objective, universally applied measurement of need, with older adults as liberal persons whose needs can be objectively evaluated as distinct from their broader social relations.  At “Belltower”, however, older adults’ independence was authorized by their privileged position as consumers who were entitled to purchase the services they desired, and home care workers aren’t equal subjects, but rather subservient producers of purchased services (page 93).  Bellower supervisors preferred workers whose moral commitments to care motivated them to do more than required by their official job descriptions.  “Belltower” supervisors like Carmen Rodriguez scrutinized potential workers’ style of dress and cooking as indicators of their caregiving skills, especially in their potential abilities to reproduce middle-class aesthetic norms as interpreted by supervisors (page 114).  “Belltower” considered itself as a matchmaking service between clients and home care workers; supervisors like Kathy Hirschorn had extensive marketing pitches and took extensive notes during the application interviews and made recommendations for home care workers based on their clients’ needs and preferences.  This comparison illustrates the ways in which “Belltower” understands its work as providing private, familial forms of intimacy and care for their clients (page 118).  During this process, older adults as well as workers are treated as though they are separate from broader social and kin relations: at public agencies like “Plusmore”, older adults are treated as either independent people whose needs are distinct from those of their broader social relations, while at private agencies like “Belltower”, older adults treated as consumers with the economic independence to freely choose their service providers.  Workers, on the other hand, are treated as employees whose concern should solely be the agency without concern or obligation for the kin that they work hard to support (page 124).

By examining home care practices as simultaneously embodied, moral, and exploitative, chapter 4 considers the ways that bodily care generates both persons and hierarchies between them (page 127).  At the heart of what both workers and older adults described as good care is workers’ abilities to regenerate their clients’ familiar ways of life.  Embodied practices in home care demand that workers quickly develop deep, intersubjective awareness of their clients’ personalities, moods, and lifetimes of experiences.  They then combined these nuanced understandings of their clients with the pragmatic skills required to maintain elders’ homes and daily routines (page 128).  HCWs’ everyday care sustains the personhoods of elderly clients by helping them live in a manner that both elders and those around them recognize as independent.  For example, when Maureen Murphy was released from the hospital, her home care worker, Sally Middleton slept on Ms. Murphy’s narrow sofa and woke up several times a night to help Ms. Murphy to the bathroom.  “Belltower” pressured Sally to spend the night at Ms. Murphy’s apartment for the first few nights after Ms. Murphy returned home from the hospital, and the profound discomfort of sleeping on the couch, plus waking up several times a night to help Ms. Murphy to the bathroom, made Sally so physically uncomfortable that she could barely walk.  “Belltower” tried to pressure Sally again to work eight-hour shifts at Ms. Murphy’s after the overnight stays ended, but Sally decided to retire from home care instead, unable to stand the physically taxing labor.  Unfortunately, Ms. Murphy took Sally’s retirement personally, feeling abandoned when she needed help the most (page 130). 

Sally’s retirement underpinned the unraveling of her relationship with Ms. Murphy and shows that the priority placed on older adults’ well-being contributes to the industry’s broader instability by overlooking care workers’ well-being.  Through their care practices, home care workers’ bodies became the ground upon which moral hierarchies between persons (the sense that some peoples’ needs and desires ought to take priority over others’) were built, experienced, and justified on a daily basis (page 130).  While discussions of embodiment often focus on earlier life, people continue to develop ways of being in and experiencing the world as they grow older; older adults enjoying the same foods and music, etc., that they did when they were younger, even as their senses diminish.  Lilian, a dying Polish client, ate the foods that her family brought over, all the Polish food she loved, even though she couldn’t chew properly, so Grace Washington, her home care worker, would blend together all of the food (page 134).  Home care workers also draw on embodied imagination to sustain clients’ social relations; in many contexts shared meals have the power to constitute both persons and their relations.  John Thomas’ home care worker, Doris, cooked for him after his wife of 65 years died; Doris didn’t replace his wife, but did wifely (nonsexual) things for him, such as cooking, cleaning, and organizing his living space (page 141). 

Home care workers furthermore accepted that they frequently work in homes that are uncomfortable and sometimes unhealthy because of their commitment to sustaining clients’ physical health and personhood.  Sometimes, living conditions were unsafe: Margee Jefferson was a hoarder who rarely cleaned her home; she had fallen and needed help around the house.  Her home care worker, Grace Washington, worked hard to make her home safe but still familiar for Margee.  Grace had disagreements with her supervisor, Carmen, about how much to change Margee’s daily schedule.  Margee woke up early for her insulin shot and went back to sleep, often sleeping until 11:00 AM, and stayed in her bathrobe for most of the day, until changing into street clothes in late afternoon in the hopes that her son would take her out for dinner.  Carmen wanted to introduce a stricter schedule with a wakeup at 7:00 AM and a daily sponge bath, while Grace thought that since Margee was elderly, it wasn’t wise to introduce such a radical schedule change (page 146).  Everyday care practices have profound moral stakes for both older adults and HCWs because of their potential to either generate or corrode personhood.  To sustain elders’ lives in ways that reflect their bodily dispositions, home care workers develop embodied knowledge of their clients’ histories of experience (page 149).  Grace had to suppress her subjective preferences in deference to Margee’s, which meant not clearing away the piles of stuff that Margee had hoarded over the years despite the fire hazard risk that Margee’s home had become (page 150). 

Chapter 5 shows how home care workers materially produce the conditions of older adults’ independence through everyday housekeeping practices (page 152).  Homes, and the care of homes, play a central role in maintaining older adults’ sense of independence in part because of the ways that home care workers’ housekeeping labor is hidden (page 152).  In the US, where conceptions of personhood are deeply tied to notions of private property, changes to homes and households can feel especially threatening, and home care workers play a crucial role in the continued generation of dwellings as homes, as places that deeply bound up with the histories, memories, and personalities of their clients (page 153).  For many older Americans, living independently means having control over the rhythms and objects of one’s household.  It also means feeling self-sufficient, yet workers’ presence in clients’ homes often threatens elders’ senses of independence.  Focusing on the independence of older adults makes it appear that the instability of CWs’ households is distinct from their paid housekeeping labor, when in practice they are intimately connected.  Workers make it possible for older adults to live independently using skills and sensibilities similar to those they used to sustain their own homes (page 155).  John Thomas had bittersweet memories of his home, as it held memories of his deceased wife, and yet he did not want to move precisely because his home held so many memories of his wife.  As previously mentioned, Doris (his home care worker) listened to John’s stories and cooked for him without making him feel that she was replacing his wife’s memory (pages 158-159).  Doris’s tact and training also allowed John the semblance of self-sufficiency and independent personhood, while still allowing Doris to do her job and care for both the home and the person who lived in it (page 169).  Grace, Margee’s home care worker, experienced the same thing as Doris; according to Grace, the trick was to make gradual modifications to people’s routines rather than to drastically upend their ways of life (170).  That way, the older adults felt independent and the workers held on to their jobs (page 171).  Within the walls of private homes, racial, spatial, and discursive practices concealments capitalize on and exacerbate broader, intersecting structures of racial, gender and class inequality endemic to the home care industry (page 175).  Some clients, such as Cecilia Tomas, preferred white home care workers so they could hide the fact that they had help (page 174).

In Chapter 6, Buch draws on cases of turnover that occurred during fieldwork to examine the ways that home care relationships were destabilized by policies and practices that treat workers and older adults as independent by restricting or penalizing forms of mutuality that sustain their relationships (page 179).  The astronomical turnover rate required looking beyond individual bad actors to looking at how the moral and material structure of home care itself perpetuated instability; approaching turnover through the lens of generative labor directs attention to the ways that home care, which is meant to sustain life, also creates inequality and unsustainability for home care workers (page 179).  Knowledge, resources, and obligation circulate between workers’ and older adults’ households, but it is workers alone who are penalized when these flows go awry (page 180).  Many older adults’ experiences of care were entwined with their experiences of kinship.  Sometimes they’d gift household goods or food, but more frequently, they’d gift time: they’d sign timecards stating that the home care workers had worked their allotted time even if they had to leave early, so home care workers could care for oft-ailing family members (page 185).  Doris Robinson was fired from “Belltower” over the misunderstanding of whether her client, John Thomas, had loaned her $13,000 or whether she had stolen it.  Mr. Thomas said that he had loaned her $13,000 to help her take care of her ailing family and fix her car, and later admitted what had happened to his next-door neighbor, Linda, when she brought him his mail to the hospital while he was recuperating from a fall.  Mr. Thomas was initially hesitant to report the loan because he felt that he did not need the money and that Doris needed it more urgently, but Linda convinced Mr. Thomas to report the incident to “Belltower” after he learned that “Belltower” had offered Doris more hours at work and she had refused.  Doris continued to insist that Mr. Thomas had loaned her the money, but she was still fired (pages 184-185).  Grace Washington was fired from “Belltower” for taking 3 personal days to herself over the course of 6 months, with relatively little notice to her supervisor (Carmen).  In one instance, Grace’s grandmother died, but Carmen wouldn’t let her take the day off to mourn with her family because Margee tended to fall and needed constant care.  Ultimately, Grace was fired for putting her own needs above Margee’s (page 189).   Describing home care workers like Doris and Grace as irresponsible or as having poor work habits insidiously misrepresents the causes of tardiness, absenteeism, and the unpredictability of their absences.  Such explanations imagine low-income workers as completely autonomous individuals whose only legitimate responsibility is to their employment, even though they were often members of under-resourced kinship and social networks in which many members face periodic and severe crises (page 197).  Home care agencies, like most other low-wage employers, very rarely formally acknowledged their employees’ responsibilities to their extended kinship networks, although informally, supervisors tended to acknowledge that workers chose home care because it offered a relatively flexible schedule that allowed them to accommodate their families’ childcare and eldercare needs (page 198).  The high worker turnover rate in the home care industry is due to multiple causes: workers’ fault (e.g., theft, missing work on short notice), inability to sustain physically taxing labor, and inability to care for others amid the profound and ongoing social and economic insecurities that their families faced (page 199).

Paid home care in the United States generates independent persons by capitalizing on inequality.  Two of the nation’s more ignored and maligned populations – the poor and the old – are bound together by work meant to sustain both of their lives (page 201).  Americans take the labor required to generate life for granted, in part because dominant notions of liberal personhood require such erasures (pages 201-202).  Living independently wasn’t just a separation from others, but a moral manner of being in relations with others: more than simply living in a private home rather than an institution, but rather also being able to live in a manner that expressed subjectivities forged over older adults’ lifetimes.  It also meant continuing to participate in social relations as they always had (page 203).  Older adults recognized that the emphatic, personalized care that sustained their ways of life exceeded the mechanistic lists inscribed in agency care plans, and older adults felt compelled to reciprocate workers’ care in other ways, such as small gifts and favors like granting time off to visit family (page 204).  Workers continued to care despite conditions of inadequate funds and public will, because social policies demanded that they work to survive and support their families, even if that work generates perpetual precarity and bodily harm (page 205).  Furthermore, workers’ reliance on welfare benefits threatens the workers’ standing as independent persons by requiring them to accept publicly-provided benefits despite working long hours (page 206). 

Buch makes several thoughtful recommendations to improving the working conditions of home care workers.  Building a stable and skilled care workforce large enough to meet current and future demand will be impossible if care workers cannot rely on these jobs to provide the living wages and benefits necessary to sustain their lives and families (page 208).  A broader group of policies aimed at creating sustainable livelihoods for care workers and other low-wage workers is necessary to grow the care workforce and to reverse increasing economic inequality in the United States.  One important policy would be to expand access to healthcare and paid leave for all workers (page 210).  Furthermore, home care workers’ experiences can contribute crucial knowledge to health care teams.  Historically, processes that formalized other healing practices and forms of health care (e.g., midwifery) devalued women’s knowledge and skills and ignored the kinds of ethics and skills people learn among kin in favor of standardized and rational methods.  Efforts to professionalize direct care work would be better served by celebrating and rewarding knowledge passed among women through familial and informal channels (page 212).  Home care workers are not formally included in health care systems or consulted by medical practitioners, and their exclusion is one consequence of the broader devaluation of care work (page 212).  Also, Buch suggests that compensating workers better would reduce the underlying causes of the most worrisome gifts (of reciprocity) and would provide occupational stability, which would in turn benefit both the workers and the elderly under their care.

Care in its current form generates longer but ever more precarious and unequal lives.  The mounting care worker shortage derives from a system that values neither old age nor the labor that sustains these longer lives (page 214).  Efforts to improve the compensation and conditions of care work have the potential to develop a care workforce that is both sustainable and valued (page 214).

​Elana Buch’s ethnography of how the lives of the elderly and the underserved intersect is thoughtful and meticulously well-researched, with several vignettes highlighting the direct impact of US policies on both professional and casual care and on the lives of both home care workers and their elderly clients.  The struggle for physical, emotional, and social independence in the face of ailing bodies and shrinking social networks emphasizes the unique vulnerabilities and needs of older adults who need the help but still want to maintain the semblance of independence.  At the same time, home care workers struggle to make a living so they can support their own families but still have professional pride in their work, wanting to provide the best care possible as they learned from caring for their own kin.  The only wish I have for this ethnography is that there could have been some follow-up with clients and workers, as many lived precariously and it would have been nice to see whether their lives improved.

Shir Lerman Ginzburg, PhD, MPH is Project Director in the Department of Pediatrics and Preventive Intervention Research Center for Child Health (PIRC) at Albert Einstein College of Medicine.