Almost by definition, households combine a wide range of caring attentions and economic transactions. Members provide each other with health care, child-care advice, information, and numerous other services. At the same time, they engage incessantly in produc­tion, consumption, distribution, and financial transfers. Feeding the family provides an obvious yet often forgotten intersection of caring and economic activity. As Marjorie DeVault (1991) has shown, the largely invisible, unpaid labor of planning, shopping, and preparing meals involves constant, often contested, negotiations of family rela­tionships. Drawing from her interviews with a diverse set of thirty households in the Chicago area, DeVault reports that women—who do most of the feeding work within households—strive to match meals with expected definitions of husband-wife or mother-child relationships. For example, appropriate meals for husbands involved enactment of deference to a man’s preoccupations and responsibili­ties outside the household. Meals, DeVault demonstrates, involved more than nutrition or economy: they routinely symbolized appro­priately gendered ties.[31]

Food acquisition and preparation, however, inform a whole set of social relations beyond gender. DeVault provides a telling example of how Janice, a nurse living with her husband and two adult chil­dren, manages simultaneously to preserve both family cohesion and independence:

Meals are often family events, prepared and eaten at home to­gether. Janice or the children decide on the spur of the moment whether or not to cook, and “whoever is home sits down and eats it.” Janice’s shopping is what makes this kind of indepen­dence possible: “What I do is provide enough food in the house for anybody who wants to eat. And then whoever is home, makes that meal, if they want it.” (DeVault 1991: 63)

As DeVault’s account implies, behind the actual feeding of the family hides a whole complex of what she calls monitoring and provisioning; watching the changing demands and consumption patterns of household members in order to adjust the supply and production of household food and searching for appropriate and affordable food. In fact, DeVault points out how regularly the women in her study either negotiated purchases by other members of the household or drew those members into the act of shopping to acquire information about their preferences. Janice, for instance, reported how she occasionally encouraged her teenage children to food shop with her: “Then they get what they want, and not what I

want. And I also get their idea of what they like. Would you rather this brand or that brand? . .. This kind of thing, where you’ve got to sort of get to know your kids, and the people you’re working with” (62). Each of her respondents, DeVault observes, “through day-to-day activities. .. produces a version of ‘family’ in a particular local setting: adjusting, filling in, and repairing social relations to produce—quite literally—this form of household life” (91).

To be sure, as DeVault shows, not all household relations of con­sumption generate harmony and collaboration. Consider another well-documented study. In his account of Philadelphia’s inner-city, poor, African-American children, Carl Nightingale reports acute rancor and conflict between parents and children in their negotia­tions over consumption. Parents exasperated by their kids’ unrea­sonable and persistent demands for spending money are pitted against children disappointed by their parents’ inability to provide them with material goods. Contest over how to spend limited family monies, including income tax refunds or welfare checks, Nightin­gale observes, severely strain household relations:

All the kids whose families I knew well lived through similar incidents: yelling matches between Fahim and his mother on how she spent her welfare check, Theresa’s disgust when she found out she was not going to get a dress because her mom’s boyfriend had demanded some of the family’s monthly money for crack, and Omar’s decision to leave his mother’s house altogether because “I hate her. She always be asking y’all [the Kids’ Club] for money. That’s going to get around, and people’ll be talking.” Also he felt that she never had enough money for his school clothes (Nightingale 1993: 159; see also Bourgois 1995).

Thus, the mixture of caring and economic activity within house­holds takes place in a context of incessant negotiation, sometimes cooperative, other times full of conflict.

Feeding and purchasing clothes by no means exhaust the caring activity that goes on within households. As the story of Barbara Pia – secka and J. Seward Johnson has already shown, health care some­times becomes even more central to household caring relationships than the provision of food and clothing. Even when medical profes­sionals provide instructions or medicine, family members regularly take part in supplying care. They assure hygiene, fetch drugs and other medical supplies, and learn medical technologies such as injec­tions and monitoring of vital signs. Household members also man­age sick persons’ schedules and their transportation, as well as the special diets and other comforts appropriate for their condition. In Los Angeles, for instance, Guatemalan immigrant women relied heavily on their interpersonal networks to secure medical care for themselves and their family members. Through a variety of informal ties, the women gained knowledge and access to both American medicine and unofficial means of healing, such as herbs, rituals, and medicines regulated in the United States but available without pre­scription in the home country.

As a consequence, mothers involved themselves daily in the deliv­ery of health care at home. Cecilia Menjivar reports on Aida, one of the Guatemalan women she interviewed in a study of such healing practices:

Like almost all the women in this study, Aida feels fully respon­sible for her family’s health needs.. .. She is always mindful of her family’s health and is industrious in putting together what­ever treatments she can find. There was a reminder to herself on the refrigerator door: Darle las vitaminas a la beiby. Ponerle las pastillas en la lonchera a Luis. (Give the vitamins to the baby.

Put the pills in Luis’s lunchbox.) (Menjivar 2002: 452-53)

Both in immigrant households and among the native born, a great deal of health care thus takes place within households. Even now, for example, the bulk of elder care still occurs in homes (Cancian and Oliker 2000: 65; Wolf 2004). Obviously, family caregiving ex­tends to an even higher proportion of sick children (Lukemeyer, Meyers, and Smeeding 2000).

For a century or so, it is true, the growth of hospitals, clinics, and medical professions moved a significant share of health care from households to professional settings. Over recent decades, however, the development of health management organizations and the aging of the American population have combined to place an increasing burden of health care on households. In 2003, a clearinghouse for information about health care offered the following impressive observations:

• An estimated 22.4 million, or one out of four U. S. house­holds engages in caring for a loved one age fifty or older.

• Between 5.8 million and 71 million family members, friends, and neighbors provide care to a person sixty-five or older who needs assistance with everyday activities.

• As many as 12.8 million Americans of all ages need assistance from others to carry out everyday activities.

• By the year 2007, the number of caregiving households in the United States for persons age fifty and above could reach 39 million.

• In California, 28 percent of residents 40 and older needed in-home care for themselves or a family member during 2002. Of those, more than half needed in-home help for more than six months.

• If the services provided by family, friends, and neighbors had to be replaced with paid services, it would cost an estimated $196 billion.[32]

Household health care is thus becoming one of America’s most formidable economic activities. How does it work? In her landmark study of health care, Nona Glazer interviewed professional nurses, home health aides, nurse managers, and social service workers about what she calls “amateur” family caregiving for acutely ill patients. With American hospital policy encouraging early discharge of pa­tients, family members, Glazer found, have taken on increasingly demanding caring tasks. She reports:

“Care” has come to encompass a new range of nursing-medical tasks. Family caregivers now monitor patients for a wide array of problems, everything from reactions to medicine to major crises.. .. The work that family caregivers learn may be fairly simple, such as supervising breathing exercises, or may be com­plex, such as keeping equipment from being a conduit for dan­gerous bacteria into the heart. (Glazer 1993: 193)

Nurses must therefore train unskilled family members and pa­tients to follow technical, often delicate, and sometimes dangerous procedures. Even immigrant families with little knowledge of English learn to use medical techniques. Glazer cites a Vietnamese family, in which only the dying patient’s husband knew English. Family members nevertheless managed to learn how to administer intravenous chemotherapy, give pain-control medication, and monitor the wife for any alarming symptoms. It took the husband, Glazer notes, ten visits to learn how to irrigate a Hickman catheter (for similar coping in lesbian/gay households, see Carrington 1999: 136-38).

To be sure, family caregiving does not always produce solidarity or result in competent attention. Family members often worry, for example, that dependent parents will outlive the resources available to pay for that care (see Abel 1990, 1991: 140-41). Glazer reports instances of antagonism, resistance, or sheer exhaustion from the stress involved in long-term demanding care work (Glazer 1993; see also Pyke 1999; Spragins 2002). Household health care taxes family resources.

Precisely because of the volume and difficulty of household health care, policy debates have intensified concerning the financial re­sponsibilities of individuals, households, and government for the provision of care. At the same time, advice and advocacy have prolif­erated. At one extreme stands the idea that each individual should take care of himself or herself, at the other that the government should be providing for universal health care. In between, however, many combinations of proposed policy and advice appear.

Since 1990, in tune with an age of privatization, a number of pro­grams have involved some form of publicly backed compensation

for nonprofessional long-term provision of family care for the frail elderly and younger persons with disabilities. These so-called con­sumer-directed programs include caregiver “allowances” and atten­dant care payments. The first arrangement provides small stipends to family caregivers ($100 to $200 monthly stipends) to subsidize everyday purchases, such as continence pads or over-the-counter medications. The monies are not intended as payments for care work. In contrast, the second program pays wages to family mem­bers, treating the family caregiver-recipient relationship as that of employer-employee (Polivka 2001: 3-4).

As of 2001, the most extensive American programs of this kind operated in California. Clients, in this state’s consumer-directed program were allowed to “hire and fire, schedule, train and super­vise” their assistance providers, which could mean their spouses, parents, other family members, friends, or neighbors. A 1999 study of the California system, funded at UCLA by the U. S. Department of Health and Human Services, concluded that family members ac­tually provided higher-quality service than unrelated workers. Spe­cifically, the study found that clients employing family care workers “reported a greater sense of security, having more choice about how their aides performed various tasks, a stronger preference for direct­ing their aides, and a closer rapport with their aides” (Doty et al. 1999: 5). Family care providers, the study noted, have a major ad­vantage over nonfamily aides: they are legally allowed to perform paramedical or medically related tasks, such as bowel and bladder care and administering medicines.

In her study of San Francisco Bay Area Chinese immigrant fami­lies, Pei-Chia Lan (2002) describes how households negotiate their relations to the California plan. Immigrants who had elderly parents to care for in the Bay Area generally chose between two arrange­ments, both of which fulfilled their obligations of filial piety. Some lodged their parents in their own homes, sometimes hiring care workers who came in during the day when the younger couple were off at work. Others hired caregivers who helped the parents in sepa­rate dwellings. In either case, family members regularly arranged transfers of legally visible wealth away from parents so that the par­ents could qualify for U. S. governmental benefits. Between the gen­erations, nevertheless, resources could flow in either direction, in the form of housing, food, money, and payments for household care work. In the latter case, lower-income households often relied on the California payment system, recruiting Taiwanese workers who took on the guise of fictive kin and frequently collaborated with the children in planning care. (In such circumstances, delicate negotia­tions took place over the responsibilities and moral performances of children and in-laws.) Although wealthy immigrants avoided state subsidies as a stigma, their lower-income counterparts treated the state payments as an entitlement, as a means of fulfilling filial obliga­tions, and as a supplement to Social Security, Medicare, and other federal entitlements. (For details of how similar plans operate in Great Britain, see Ungerson 1997, 2000.)

Other experimental public programs have tried paying poor women for the care of their own sick or disabled children, thus, ironically, formalizing them as paid providers of care. Consider Tasha’s case, as reported in a study of strategies used by welfare – reliant mothers caring for children with chronic health conditions or disabilities after the welfare reforms of the early 1990s. Tasha, a forty-five-year-old unmarried African-American living in Cleveland with her two children, had first dropped out of Ohio State Univer­sity to care for her sick father. She then became primary caregiver for her daughter who had a severe seizure disorder. Pushed out of welfare, she managed to get hired by an agency that paid her a low hourly wage without medical benefits for thirty hours of weekly care work. The meager salary helped redefine Tasha’s social standing: [33]

In this case, the entry of paid care into the household by no means undermined its moral economy; quite the contrary. (On paid kinship foster care for children, see Geen 2003.)

Nevertheless, as we might expect, such policies incite acute moral and political debates, often with hostile worlds warnings about the contamination and undermining of moral obligation (Olson 2003). The 1999 California report summarizes pros and cons of employing family caregivers. On the plus side, supporters argue that paying family members is sometimes preferable to involving strangers in what are often very intimate forms of assistance. This sort of pay­ment, they contend, actually “reinforces natural caring relation­ships.” On the minus side, critics worry that paying people “for meeting moral obligations within the family system” is both fiscally irresponsible and morally corrupting, escalating public expenses and at the same time “distorting family relationships.” Equally alarming, critics contend, is the reverse contamination: “Emotional ties and complex family relationships can complicate and even undermine what should be a business-like service relationship.. .. Firing a fam­ily member (especially one who shares your household) in case of unsatisfactory job performance may be extremely difficult, if not im­possible” (Doty et al. 1999: 11).

Note that opponents of state-paid family caregiving invoke the now-familiar dual ideas that the intrusion of the marketplace into the sacred space of the family inevitably brings corruption, while introducing sentiment into the workplace reduces efficiency. Even supporters remain wary. The 1999 report notes that California county case managers are trained to “identify and to subtract out the services (such as housekeeping and meal preparation) that family members living in the home who are not themselves disabled should be able and willing to provide without being paid” (39). By this pol­icy, they thus displace but still protect the boundary between appro­priately commercial and intrinsically noncommercial zones of care.

Despite these innovative government policies, the majority of household members remain responsible for unpaid provision of each other’s health care. As a consequence, they regularly confront both routine and exceptional economic responsibilities. Recognizing such responsibilities, a number of advocacy organizations provide advice to family caregivers. For example, family consultants at the Family Caregiver Alliance urge adults who are deciding whether to move a dependent parent into their home to consider such issues as these:

• What will the financial arrangement be? Should I charge rent? Will I have expenses for her to cover?

• How will my siblings feel about the financial arrangement?

• Will my work situation have to change, and if so, how will I cover the bills?[34]

Here, as elsewhere, economic arrangements for the provision of care do not simply call up considerations of cost, convenience, and effi­ciency. They involve negotiation of the forms, representations, obli­gations, and rights attached to meaningful interpersonal ties.