NPR featured a story tonight about how poorly compensated home health care work is. Currently, they are not entitled either to the minimum wage nor to overtime pay. Most make between $8-10/hr., while the company that employs them pockets the $18/hr. payment from Medicare. Spokespersons for the home health-care industry were permitted to whinge and whine about the terrible hardship that a minimum wage and overtime requirements would put on their businesses.
The tone of the story tilted towards compassion for the workers and their clients, but they story’s historical perspective looked back only 40 years when I think a critical component of this story is the longue durée of this kind of low wage work, work that now (as in the past going back at least 500 years) is performed overwhelmingly by working-class women, and in the Americas for the most part, by black and brown-skinned working-class women.
Intimate body care has never been a well-compensated occupation. Perhaps one reason for this is that a great deal of nursing of the young, the sick, and the elderly was done by volunteer caregivers who went by the names mother, sister, and/or daughter. Families who could afford it in North America, from the colonial period to the present, hired help from among working-class women. Working-class women (including indentured servants and enslaved women) were after all the experts in early modern and modern intimate body care, from prostitution to wet-nursing to early child care, sick nursing, and elder care. It’s important to see all of these occupations on a continuum, as the modern West (and perhaps other cultures in other places and times) has either expected this kind of intimate labor either to come for free (from women intimates) or to be offered at very cheap rates.
It seems like the closer you have to work with other people’s bodies, the lower your pay and occupational status. These hierarchies are visible not only between occupations (home health aids versus car mechanics, for example) but even within industries. For example, consider the relative status differences among L.P.N.s, R.N.s, and M.D.s. Yes, your physician touches your body during examinations, but a great deal of diagnoses are made on the basis of high-tech tests and lab values that are performed by other people below the M.D. In general, people lower down on the medical work hierarchy have to touch you a lot more often, and they have to clean up any messes you make.
Readers of this blog should also consider how bodily intimacy in our work environment decreases as the relative prestige among teachers and professors rises: early childhood caregivers and elementary school teachers are at the bottom–they not only deal with the youngest students, but are much more intimate with them either in showing affection or even cleaning up their snot, vomit, or urine. Then we have secondary school teachers, and then college and university proffies (with a similar hierarchy ordering those who work with younger undergraduates and/or older graduate and professional students). Administrators always make more money than the people who are in direct contact with students. In fact, even among professors, the fewer students you teach, the higher your prestige and pay: we too expect that the higher our teaching loads and “student contact hours,” the lower the pay and prestige of the job.
Clearly, this is a cultural or societal issue that can’t be addressed by changing a few laws or increasing Medicare reimbursement for home health care. I would welcome your thoughts and expertise on this issue.
Historiann 
Let us not forget the unpaid caregivers. May I suggest reading Emily Abel’s _Hearts of Wisdom: American Women Caring for Kin, 1850-1940_
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The NYT made an interesting point today, embedded in a much larger article on the differential impacts of the “Great Recession” on various age cohorts, to the effect that while the occupational outlooks of unemployed people over 55/60 have darkened considerably, the life expectancy of aged persons typically rises during such crises. The next sentence attributed this phenomenon (conjecturally, and not in front of me now) to the fact that in such circumstances, and presumably only in such circumstances, a much wider swath of the employable population is willing to take home care and nursing home employment, with the effect that more care is delivered. There were, to be sure, no data presented with this proferred correlation, or even any broad attribution to studies. The implication seemed to be that it was merely a function of the relative density of care, and not any changes in its fundamental character.
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This is very interesting to me in the context of theatre, specifically costumes. I work in university level theatre training as a costume designer and instructor, and have always noted the pay disparity between costume workers, who help the actors change their clothes, and are very intimate with them– seeing them naked, handwashing intimate clothing which is sometimes stained with bodily secretions of various types, and also dealing with their emotional reactions to things– and the people who run the technical things, lighting, sound and scenery. It is very clear that the lighting, sound, and scenery people are more valued, at least in the payment sense, but it would be very hard to have good theatre without this very close, intimate care of the actor.
Even in non-paid, student work, it is generally very difficult to find people who can do this work well, because they really have to perform what can feel like maid service with lovingkindness and give very completely of themselves, and I feel that is harder than programming a computer or shifting scenery. Often, though, we are given the “leftover” students who don’t do well in other areas instead of people who really want to give of themselves, and they do not stay, as it is a very difficult thing to do.
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In books on the history of the senses I have seen scholars delineate a hierarchy of the senses, with sight and hearing being represented in early modern pictures as superior (and distanced) while smell and touch and taste being classified as lower and devalued.
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I find myself wondering about the possibility of home health care workers setting up some sort of cooperative. They’d still need to pay people to deal with scheduling, billing, etc., which would shave something off the $18/hour (which sounds low; I’m pretty sure that we were paying more than that to a private agency in my grandmothers’ last years 15 years ago), but I suspect it would be possible to pay an appropriate wage to an office administrator/scheduler/reference-checker or two, an off-hours phone answerer, and a bookkeeper, and still raise the workers’ hourly wage by at least a few dollars.
Another problem: such workers are often considered independent contractors, so they end up paying the whole social security tax (just as academics do when we freelance), and don’t get benefits. That’s a huge bite from one of our most regressive taxes.
In the academic context, the wages seem to be lower not only if one has frequent one-on-one contact with a significant number of undergraduates (especially freshmen and sophomores), but also if one spends significant time handling their work (papers, lab reports, problem sets, etc.). That the physical versions of such exercises often seem likely to carry germs (I’ve been handed papers with hands that recently wiped a nose, without the aid of a handkerchief) only strengthens the parallel. I also suspect that lower-paid academic workers are more likely to find themselves dealing with crying students (in their offices and/or classrooms), and perhaps even those who seem to be having other sorts of breakdowns. We certainly learn lots of intimate details about their lives, including many that strike me as TMI.
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The see/teach/touch hierarchies caught me unprepared. Political/social hierarchies are what usually works for me. All the hierarchies in the examples are also political (e.g. power and influence). Will sleep on the post’s analysis.
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This is literally one of my favourite topics to read and write on!
I would add that not all bodily servants were badly paid; working for the royalty and the aristocracy in such sensitive positions could be quite lucrative, primarily because such servants often had access to sensitive information and should really be kept loyal. And such roles were not always done by the lower classes. But, I sometimes wonder if these are the exceptions that prove the rule. In the 18thC at least, many people, especially elite men, felt very vulnerable to exposure by those that had access to such intimate areas of their lives (wives, servants, etc). I would also argue that this gave those who provided intimate care agency within those relationships that they could use in negotiations of power (which is not to say that the balance of power was ever shifted in their favour). I wonder whether the diminishing of care-givers in economic and social terms acted to reinforce the power of the care-receiver when they were in a vulnerable position.
To add to Sisyphus’s point on the hierarchy of senses in the early modern period (and there was some debate on the exact nature of the hierarchy), touch was viewed as lesser because it was thought to be ‘less accurate’ as a method of observation.
And finally one of my favourite pieces of writing on this topic is Kathleen Brown, “Body Work in the Antebellum United States,” in Ann Stoler, ed., Haunted by Empire.
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This is interesting. This hierarchy also plays out among medical professionals, with surgeons at the top of the heap dealing intimately with people who are knocked out, while nurses deal with them while they are awake and often in pain. Yes there are of course surgical nurses, but they mop up and hand things, they aren’t as intimately involved as the surgeon.
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Consider the caste structure in India, which based on very limited knowledge follows your hierarchy.
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It seems to me the correlation goes in the other direction: intimate contact with your cares / manual labour is devalued / difficult, so people with training and prestige can choose to avoid it.
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Great comments–thanks, everyone! Sisyphus, I need to read some of the stuff you’re talking about! I wasn’t aware of the hierarchy of the senses, but that certainly seems to me to be relevant here.
I love Sophia’s example from the work of the theater, which appears to map exactly as I might have guessed. I also think Contingent Cassandra’s point about papers/submissions as proxies for student bodies is really interesting. (And sometimes they may be as pathogenic, too!)
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To digress….
[nelson]
HA, HA….
[/nelson]
http://www.insidehighered.com/news/2013/02/04/coursera-forced-call-mooc-amid-complaints-about-course
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Indyanna —
here:
http://www.nytimes.com/2013/02/03/business/americans-closest-to-retirement-were-hardest-hit-by-recession.html
“Death rates for people over 65 have historically fallen during recessions, according to a November 2011 study by economists at the University of California, Davis. Why? The researchers argue that weak job markets push more workers into accepting relatively undesirable work at nursing homes, leading to better care for residents.”
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And, this: The whole ball-up regarding the working classes tending to the uppers during Sandy brought this issue forward — that, and the debates over “allowing” janitorial and food service workers paid sick leave, so their body-service doesn’t make their employers (and customers, by extension) sick:
http://dinersjournal.blogs.nytimes.com/2012/11/01/uptown-the-deluge-is-customers/
http://www.cnn.com/2013/01/30/opinion/jarayaman-flu-food-workers/
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@Indyanna–
That paper Doug Miller and coauthors (based on a much earlier paper by Christopher Ruhm) has gone through a number of iterations. (Other potential explanations were pollution, traffic accidents etc.) It’s neat that they finally nailed it down. http://www.nber.org/papers/w17657
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Fascinating post, Historiann!
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Wonderful post!
I think another reason intimate care of the sick is denigrated (and hence heavily gendered female) is because of the phenomenological recoil that the healthy able-bodied often experience from the sick.
Sick bodies represent a rupture with the order of the world, and there is a danger, a sense of contagion that goes above and beyond that which flows from infectious disease. (Consider why small children are often afraid of hospitals even when they lack a clear sense of communicability, and many an adult fears hospitals precisely because of what happens therein).
Coming into contact with the house of sickness, with wounds, putrescence, and with death is therefore in many Judeo-Christian contexts a task left for the disenfranchised. Moreover, because sickness is deeply connected to notions of desert (the Latin root for pain is punishment), caring for the wicked is the province of she who is responsible for original sin itself.
I think some scholars estimated in 1999 the value of informal caregiving — overwhelmingly provided by women, of course — at in the neighborhood of $300 billion, which is both a conservative estimate and is almost completely un or underreimbursed.
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Thanks, everyone. I continued to think about this issue all day long.
Daniel makes a great point about the supernatural or spiritual contagion of the sick. The only think I would add to his comment is that care of the sick was also taken on by women religious, who embraced their work as a kind of ultimate debasement and humility. IOW, their work was as much about humiliating themselves by taking on the most disgusting and degrading work as it was about charity for those who were too poor or alienated from family who would otherwise be expected to provide care for free (the women in the family, anyway, as Daniel notes.)
I also wonder about status w/r/t the care of people who need more intimate body care. Most of those people are either very old, very young, and/or very sick–IOW, relatively low-status people. So is it the intimacy of the care required, or the fact that it’s performed on low (or lower) status people that degrades the work?
Nursing, like teaching, was first undertaken outside of the family context by women religious (for the most part. Men religious also taught, but I know of no male religious orders whose apostolate was nursing, like the many orders of Augustinian nuns.) This is just an observation–I welcome everyone’s further comments on this.
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p.s. An email correspondent suggested that this book might be interesting to anyone engaged by this subject: Eileen Boris and Jennifer Klein, Caring for America: Home Heath Workers in the Shadow of the Welfare State (2012).
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“Intimate body care has never been a well-compensated occupation. Perhaps one reason for this is that a great deal of nursing of the young, the sick, and the elderly was done by volunteer caregivers who went by the names mother, sister, and/or daughter. Families who could afford it in North America, from the colonial period to the present, hired help…It’s important to see all of these occupations on a continuum, as the modern West (and perhaps other cultures in other places and times) has either expected this kind of intimate labor either to come for free (from women intimates) or to be offered at very cheap rates.”
Joanna Russ, in What Are We Fighting For, made the point that, if all the intimate care (here including housework), currently provided for ‘free’, were paid at the rate prevailing in the money economy, the entire money economy would have to be transformed. She turned the reasoning around — it’s not that intimate body care (which is unpredictable in its moments, but chronic and long-term, requires attention and judgement, but does not allow of career advancement, and is not bound to any reasonable shift schedule) traditionally falls to low-status people because $reason. It’s that whole swathes of the population have been assigned low status precisely to make them available for this low-status work, which the more powerful factions really wanted to receive but really did not want to pay fairly for.
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It’s why I cringe when reading articles that muse that one of the best reasons childless women should have some is to have someone to take care of them in their elder years — which, if you care about children as autonomous beings, feels repellent and damn-near slave-based.
Children should be born to be loved and nurtured toward independence — but that’s not how it is in most of the world, so I’m just positing a first-world pie-in-the-sky belief.
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I saw the same story Indyanna did.
Is it possible that as we all grow older, and we see more clearly that the quality of life in the last ten years relies so heavily on good–I mean good–help, that this profession will become more valued, and better paid?
But maybe not. Because most of us won’t have much money to pay them.
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Great points, Historiann!
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Somehow this is in the zeitgeist… most likely due to heterosexual *men* having to take up these service roles more or less permanently….
“Andrew O’Connell at the Harvard Business Review, cited in Resnikoff’s piece, looked at the actual pay rates for emotional labor in 2010:
When men move to jobs that require increased cognitive labor, they get an 8.8% wage boost, on average. But when they shift to positions demanding higher emotional labor, they take a 5.7% cut in pay relative to occupations with lower emotional demands, according to Devasheesh P. Bhave of Concordia University and Theresa M. Glomb of the University of Minnesota. (With women, the story is similar, but different: They get no financial reward for greater emotional labor either, but they don’t get a penalty—their wages stay flat when they make a transition to higher emotional labor.)”
http://inthesetimes.com/working/entry/14535/grin_and_abhor_it_the_truth_behind_service_with_a_smile/
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Here’s another possibly-relevant example: a County Executive convicted of misusing public employees in a variety of ways. The example that seems to have most shocked the judge was the way Leopold treated his (female) scheduler after a back operation, having her drain his catheter for him long after he was able to do it for himself:
http://www.washingtonpost.com/local/ruling-in-john-leopold-trial-expected-today/2013/01/29/36ec7680-6a47-11e2-ada3-d86a4806d5ee_story.html
A few excerpts (out of the order in the story, to restore chronological order):
“The trial’s most compelling testimony came from Medlin, 63, who described how several times a day over nearly a year, her boss would summon her to drain urine from his catheter bag. Leopold required the catheter after back surgery in February 2010.
Medlin cried as she detailed how she had to follow him into a restroom and get on her hands and knees to empty the urine into a coffee can kept under the sink. In early 2011, she became upset after seeing Leopold bend down to tie his shoelace, and she realized that he had been making her do it even though he was able to do it himself.”
“Sweeney [the judge who rendered the verdict in the non-jury trial] described the behavior of the second-term Republican as “outrageous, egregious and wildly beyond” any authority he has as county executive and said his treatment of his scheduler, Patricia Medlin, in particular was “predatory and cruel.””
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