The World Is Aging

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Review of Lisa Eckenwiler, Long-Term Care, Globalization, and Justice (Johns Hopkins University Press, 2012).

The world is growing older. During the past centu­ry, life expectancy has increased by nearly thirty years. By 2050, one-third of the world’s population is expected to be age sixty and over, and between 2000 and 2050, the percentage of people age eighty and over is projected to more than double.[1] These changing demographics are predicted to create a “surge” in demand for long-term care.[2] In the United States, about 70 percent of people age sixty-five and older will need at least some long-term care services before they die.[3] A study published in 2012 estimates that, despite declines in severe disability, aggregate spending on long-term care among people age fifty-five and over will increase 56 percent between 2007 and 2030.[4] Despite these remarkable figures, policy makers at the federal level have done little to expand access to long-term care. At the state level, there is a great deal of activity concerning policy, though most of this interest is aimed at efforts to limit Medicaid spending on long-term care.[5] In the absence of com­prehensive policy reform, the United States, like most other developed countries, relies on a patchwork system of formal and informal care. The majority of this care is provided by women and, among paid caregivers, many of these women are from lower-income countries.

Lisa A. Eckenwiler’s book Long-Term Care, Glo­balization, and Justice both describes and evaluates the global system of care work. Eckenwiler uses “eco­logical thinking” to explain the “increasingly transna­tional connections that organize and constitute long-term care” (p. 3). Beyond description and explanation, the book seeks to use the ecological perspective to guide long-term care policy and assess the ethical implications of the “interdependence among particu­lar policy sectors, places, and people” (pp. 3-4). She argues that describing these connections helps policy makers understand how the existing system generates global injustice and can guide policy solutions.

In the first section of the book, she documents the growing need for long-term care and describes the lim­ited and fragmented nature of long-term care policy in the United States. In recent years, there has been a shift from in­stitutional care to more home- and community-based care, but formal home-care services are usually pro­vided by workers with little training and very low pay. There is a lack of integration and coordination among different kinds of care, and the “trend in long-term care since the 1980s has been toward decentralization, privatization, and informalization” (p. 19). Further­more, most people who need long-term care services in the United States receive them, not from this fragmented formal system, but from “informal” caregivers—family, friends, and neighbors. Caregiving, as Eckenwiler ex­plains, “lacks social standing and garners little respect in many countries, and is not typically seen as work, or in economic terms, as productive” (p. 22). This at­titude further undermines support for public spending on long-term care.

There is, of course, a vast literature on working conditions of paid caregivers. In 1991, Deborah Stone noted that the low wages paid to personal assistants and home health aides “only shift[s] the unaccept­able economic burdens of family care onto strang­ers.”[6] Eckenwiler builds on this idea and highlights the transnational flow of nurses and other care workers. She argues that neoliberal economic policies may well be the greatest contributor to the modern-day move­ment of care work around the world. She claims that World Bank and International Monetary Fund (IMF) policies have encouraged countries in the global South to shrink their public sector. These policies have, in many cases, reduced employment in the health care sector. Coupled with immigration and labor policies in host countries, they have encouraged women to seek employment in the United States and other countries in the global North. A great strength of the book is Eck­enwiler’s discussion of how policies in a host of seem­ingly unrelated domains helped create the conditions under which paid caregivers from the South have be­come an important source of formal long-term care in the North.

Indeed, Eckenwiler focuses our attention on global inequalities produced by the “structures and processes that organize long-term care labor and connect people around the world” (p. 70). She argues that the global system of long-term care creates “structural” injus­tice in which there is a “systematic contraction of op­portunities for some as the opportunities of others expand” (p. 72). Older people who require long-term care services and supports in the United States are vulnerable, but less so than those in “source countries that have care worker shortages. Family caregivers in the North struggle. . . . But they are better situated than emigrant care workers” (p. 72).

But what criteria should we use to assess these global inequalities? Eckenwiler builds on the ideas of “justice as enablement” and the capability approach developed by Amartya Sen and Martha Nussbaum to articulate her own concept of justice. The capability approach argues that judgments about social justice should depend on the extent to which policies and practices provide opportunities for people to lead lives they have reason to value. She argues that the focus on capabilities is appropriate, but the work of schol­ars who focus on capabilities places an “emphasis on the self in articulating the ideals of global justice” and thereby “serves to obscure our interdependence and need for caring relations” (p. 78).

The realization that capabilities must be under­stood in the context of interdependence is important, to be sure, but it does not address some of the more fundamental questions about the capability approach. It helps to advance the conversation about responsibil­ity and the degree to which people in the global North have responsibility for the situation of caregivers from, and those still living in, the global South. It ignores, however, difficult questions about how to assess capa­bilities. Which capabilities are most relevant? Should we try to articulate a universal list of morally relevant capabilities or should these vary from society to soci­ety?[7] Because she is silent on these issues, Eckenwiler does not offer a precise set of criteria that could be used to evaluate justice in long-term care policy.

Another important shortcoming of the book is its limited discussion the literature on U. S. long-term care policy and of feminist scholarship.[8] In the first chapter of the book, Eckenwiler quotes from a study by Edward Miller and colleagues in which they assert that “long-term care is ‘no longer viable’” (p. 2). She claims that, despite the growing need for long-term care in the United States, there is a “policy void” (p. 2). Indeed, one significant new policy initiative, the Community Living Assistance Services and Supports (CLASS) plan that was part of the Patient Protection and Affordable Care Act, has been delayed indefinitely by the Obama administration. It would have provided modest fund­ing home- and community-based long-term care. Eck­enwiler does a nice job of discussing the consequences of this policy void, particularly the implications for global injustice, but she pays inadequate attention to the issue of gender and how this helps to explain the existence of the void. Feminist scholars argue that the failure to develop adequate financing for long-term care, the failure to recognize the value of informal care­giving, and the perpetuation of low wages for the work of paid caregivers are due to the fact that this work is done primarily by women. As C.L. Estes explains, “the cumulative economic disadvantages of both un­paid caregiving and wage inequality for women largely explain why there is an overall retirement income gap of 56% for women compared with men. . . . A signifi­cant limitation on old age policy is that the dominant power group, white men, does not share equally with women the benefits of the longevity revolution.”[9]

These omissions notwithstanding, Long-Term Care, Globalization, and Justice is an important book that raises critical questions for scholars in public pol­icy and ethics. Even though policy makers in the United States seem content to ignore the issue of long-term care, scholars in policy and ethics should continue to docu­ment the consequences of existing policies and to de­bate criteria that should be used to assess them. This book contributes to those goals.

[1].  M.K. Gusmano and K. Okma, “The Bright Side of Aging: Reframing the Debate” (unpub­lished paper presented at the annual meeting of the American Political Science Associa­tion, Washington, D.C., September 2, 2010).

[2]. R.W. Johnson, D. Toohey, and J.M. Wiener, “Meeting the Long-Term Care Needs of the Baby Boomers: How Changing Families Will Affect Paid Helpers and Institutions,” The Re­tirement Project: Discussion Paper 07-04 (Washington, D.C.: Urban Institute, May 2007).

[3]. See P.S. Arno, M. Gusmano, and D. Viola, “Administration Reveals Lack of CLASS,” Bioethics Forum, November 15, 2011, at

[4]. C.A. De Meijer, I.M. Majer, M.A. Koopmanschap, and P.H. van Baal, “Forecasting Lifetime and Aggregate Long-Term Care Spending: Accounting for Changing Disability Patterns,” Medical Care 50, no. 8 (2012): 722-29.

[5]. A.W. Housser, W. Fox-Grage, and K. Ujvari, “Across the States 2012: Profiles of Long Term Services and Supports,” AARP Public Policy Institute, September 2012, at

[6]. D.A. Stone, “Caring Work in a Liberal Polity,” Journal of Health Politics, Policy and Law 16, no. 3 (1991): 550.

[7]. M.C. Nussbaum, “Capabilities as Fundamental Entitlements: Sen and Social Justice,” Feminist Economics 9, no. 2/3 (2003): 33-59.

[8]. C.V. Browne and K.L. Braun, “Globalization, Women’s Migration, and the Long-Term-Care Workforce,” The Gerontologist 48, no. 1 (2008): 16-24; C.L. Estes, “Women, Ageing and Inequality: A Feminist Perspective,” in Cambridge Handbook of Age and Ageing, ed. M. Johnson (Cambridge, U.K.: Cambridge University Press, 2005), 552-62; and C.L. Estes, “So­cial Security Privatization and Older Women: A Feminist Political Economy Perspective,” Journal of Aging Studies 18, no. 1 (2004): 9-26.

[9]. Estes, “Social Security Privatization and Older Women,” 12, 23.

  • Michael Gusmano

    Dr. Gusmano’s research investigates the consequences of health and social policy for poor and other vulnerable populations.

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