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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2007.117390
LETTER |
At the time this letter was written, Lisa A. Eckenwiler was with the Department of Philosophy, Institute for Ethics and Public Affairs, Old Dominion University, Norfolk, Va.
Correspondence: Requests for reprints should be sent to Lisa A. Eckenwiler, Department of Philosophy, Center for Health Policy Research and Ethics, George Mason University, Robinson B 472C, 4400 University Drive, MS 2D7, Fairfax, VA 22030 (e-mail: leckenwi{at}gmu.edu).
Talley and Crews deserve praise for their Journal contribution on caregiving. Their model, which sees caregivers and those they care for as situated within "societal, political, and scientific [forces] that shape the context of care,"1(p27) can help advance understanding of the plight of dependents and their caregivers, enable researchers to formulate innovative new questions, and help policymakers to envision better strategies to respond to the needs of these vulnerable people.
I propose that we invoke an "ecological" model for thinking about caregiving in all its complexity.2 An ecological perspective illustrates the ways in which the world of caregiving, usually seen as a set of disparate parts, is in fact a complex whole. This framework, although similar to the one set out by Talley and Crews, adds needed depth to analyses of caregiving and highlights additional features of the landscape. An ecological framework shows the needs of dependents and caregivers as intertwined and vividly reveals that decisions made in different policy sectors—health, labor, economics, and, notably, immigration—affect decisions made in others and profoundly affect the lives of givers and receivers of care. In addition, such a framework demonstrates that not only is caregiving affected by the actions (or inactions) of government policymakers, it is also shaped by the practices and policies of both nongovernmental and for-profit agencies that cross national borders, such as international lending bodies and nursing recruitment agencies. These transnational agents contribute to the migration of women from developing countries who are seeking better-paying caregiving work abroad—migration that may serve to undermine working conditions for paid caregivers who are citizens of the United States and also to perpetuate global health inequalities.
An ecological analysis of caregiving yields a different picture than one generated by examining, in isolation, singular issues to which caregiving is related. Thinking ecologically, we can ask: what does quality of care have to do with labor policies? What do employee leave policies and cost cutting in health care have to do with the long-term health status and economic security of family caregivers? How do US health and labor policies encourage the migration of nurses? What do the working conditions of paid caregivers have to do with the quality of care that dependents receive? What do health care hiring practices in the United States and the policies of international lending agencies have to do with global health inequalities?
By emphasizing "the constitutive part played by multiple and complex interconnections,"3(p38) an ecological analysis shows that the current caregiving system is organized in a way that leads to inadequate care for some and little or none for others, undermines the well-being of caregivers, and threatens to perpetuate global health inequalities.
Accepted for publication May 8, 2007.
References
1. Talley RC, Crews JE. Framing the public health of caregiving. Am J Public Health. 2007;97:224–228.
2. Eckenwiler LA. Caregiving in the Context of Globalization: Toward Justice for All. Baltimore, Md: Johns Hopkins University Press. Forthcoming.
3. Code L. Ecological Thinking: The Politics of Epistemic Location. New York: Oxford University Press; 2006.
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