Maria Angeles Duran: “health care has always been women’s work”
Under the auspices of Chile’s National Health Fund (FONASA) and the Pan American Health Organization, Spanish expert Maria Angeles Duran recently presented a course in Chile entitled “The Invisible Costs of Health Care,” a subject which she has addressed in numerous specialized publications. The “invisible costs” to which Ms. Duran refers are those produced outside the institutionalized health-care system: the labor of health care that generally fails to women in the home. Over the past few decades, due to the aging of the population, a huge increase in home care has occurred in many countries around the world.
What phenomena have led to an increase in health care provided outside of the formal health-care system, care that is increasingly referred to as “home care”?
In both developed and developing countries, two changes are having a major impact on the field of health care. One is the aging of the population. Not very many years ago, in various regions of the world the demographic pyramid had a wide base and a very narrow ceiling. The shape of this figure corresponded to a great number of births (the base of the pyramid) and a small population of senior citizens (the needle roof of the pyramid). However, in many countries today, the probability of dying in the first 65 years of the life cycle is quite low for both men and women. This low death rate explains the sustained increase of the population of senior citizens, which is reflected in the pinnacle of the demographic pyramid, whose form is becoming more and more rectangular as a result of these changes.
The second change is the growing incorporation of women into the labor market. The combination of both of these factors will require the health-care system to change drastically in coming years in order to respond to the consequences of this situation. In effect, because of the aging of the population, in the upcoming years we are going to have to confront the predominance of degenerative and chronic diseases. These kinds of illnesses will require more non-intensive medical care, or at least less intensive care, as well as more social health-care services.
For example, in an operation for appendicitis, the health-care system will provide approximately half of the time necessary to care for the needs of the “patient,” in the way of examination, diagnosis, surgical intervention and immediate post-operative care. The other half of the care will have to be contributed by the person’s own family: providing transportation to the health center for tests or examinations and special recovery care following the intervention.
However, with a chronic illness like Alzheimer’s disease, something very different occurs. In this case, the time the doctor takes to diagnose the illness and recommend appropriate therapy accounts for only 0.5% of the total care, whereas the family members will have to fulfill the remaining 99.5% of care in the immediate social environment. In the case of chronic illnesses, it is not the medical intervention which is most needed, but rather the work of caring and providing personal attention at another level.
So chronic illnesses demand a great deal of time within in the home.
Of course. As long as the number of elderly people and the rates of degenerative diseases continue to rise, the demand for home care will increase. The sick who are being cared for at home will require transportation, feeding, cleaning, assurance of a safe environment etc., but not as much work in the way of diagnosis and therapy. Care for chronic illnesses lasts many years and requires an enormous amount of dedication. We must also bear in mind that after age 75 people usually experience a progressive loss of their physical and mental capacities until they reach a state of almost absolute dependence in the more advanced years.
We must also remember that caring for the sick in a medical center requires the participation of many others who are not doctors or nurses – those responsible for administration, maintenance, nutrition etc. These responsibilities represent an important component of the hospital personnel in addition to the obvious job of providing medical care.
How does this reality relate to the fact that women’s incorporation into the labor market continues to increase?
The organization of the health-care system is based upon the assumption that there always will be someone available in the home – preferably a woman – to provide services to anyone who might need it. In reality, there are more and more homes in which no one is available to assume these responsibilities. For instance, today in many countries of the European Union, over one-third of all homes are inhabited by only one person. If these individuals were to need intensive care, the healthcare system would not equipped to respond to their needs.
The phenomenon of the single-person home demonstrates that medical and health-care services cannot be based upon the belief that the sick person lives with other family members. Throughout all of Europe, for example, the single-person household constitutes around 30% of the total number of homes, but there are some countries in which more than 34% of all households are single-person homes, and this rate is on the rise.
Many other regions are also witnessing this same process of the aging of the population. Today, about 10% of Chile’s total population is over age 60, and it is estimated that in 20 years this figure will climb to 14%. However, this doesn’t mean only a 4% increase as the percentages seem to suggest, but rather that the total number of older people will actually increase by 40%.
To demonstrate the complexity of the situation, let us suppose that there are a total of 100,000 hospital beds available for geriatric residence at any given time. However, with this increase in the percentage of the elderly population, 140,000 beds would be needed to provide services to the same proportion of senior citizens. And if services are not increased by 40%, there will be less care available than before.
Nonetheless, as increasing numbers of Chilean women enter the labor market, even this 40% increase in services for the elderly will not be enough. Even more institutional care will be needed since many women will not be able to continue to care for ailing, older family members; the partial transfer of home care to the domain of institutional care is inevitable. In other words, the services offered by the traditional family are being reduced while the demand for institutional services and care continues to increase.
Alzheimer’s disease is probably one of the most common diseases among the elderly as well as demanding the greatest amount of care outside of the hospital.
That’s correct. There are studies in some countries which show that about 50% of the population over 85 years old suffers from this disease at an advanced stage. In Europe, it is expected that, within 25 years, the number of people over age 85 will triple, and therefore, the demand for health-care for people suffering from Alzheimer’s will increase as well. And in order to maintain the same level of care, three times the amount of services will be needed, assuming that families can provide the same amount of home care. However, as I have explained, the amount of home services most likely will decrease even as the demand for these services increases…
In addition, the demands by the aging population may even increase beyond these expectations. This older population may become accustomed to new services that were not previously offered, and they may expect better quality care as well. To summarize: demands will grow and the expectations will increase, while care provided by the family will shrink.
Undoubtedly the aging of the population is going to affect the entire system of social services.
Of course. For example, another transformation that will have a tremendous impact is the breakdown of the pension and tax systems that we have known up until now. We will have to confront various ethical and political issues, even the concepts of life and death; the very priorities of biomedical research will need to be changed in order to approach the matter of old age as a priority.
In addition, there have been many changes in international relations due to the massive arrival of immigrants, who are frequently employed as caregivers for the elderly. In Spain, this issue is of extraordinary importance: almost all of those employed to care for the elderly are Latin American women, especially from Ecuador and the Dominican Republic. This employment was initially clandestine, performed illegally without work permits, but legislative changes have improved working conditions and home care provided by immigrants is now more formalized…
What percentage of women in the European Union are economically active?
The percentage varies among countries. The highest rate is observed in the Scandinavian countries while Spain and the Netherlands have the lowest percentages of women incorporated into the labor force. But we have to be careful with the interpretation of the data. In many countries, unemployment rates for women are double those of men. And because the unemployed are considered a part of the active population looking for work, in some cases the percentage of economically-active women increases not because they are working, but rather because they are unemployed.
In the European Union there now is a widespread effort to reduce unemployment among women and their dependence on other members of the family. But there are tremendous differences among the EU countries with respect to women’s workday, for example, and to the issue of shared, clandestine and informal jobs which are so frequently performed by women. As a result, it is difficult to have a clear understanding of the real situation of women’s work.
Are there studies that show how women’s health is affected by being responsible for health care in the home?
There are no studies that have precisely measured the effect of this responsibility although there are several research projects related to this issue currently underway. However, they do not yet provide statistics on female mortality in a particular age group because of their jobs as caregivers or because of the burden of their multiple roles caring for the elderly, performing unpaid domestic work, and working for pay outside of the home…
However, there has been an increase in society’s awareness about the additional burden that women carry, especially those of middle age — 50 years or older — with a lower educational level. Just a few years ago, although it was not explicitly stated, it was well understood that women ‘had to” do this work and that no one thanked them or recognized their efforts. Nevertheless, women have historically made an incredible contribution to the health of the population and have been a key part of the overall healthcare system.
Since women typically live longer than men, it is also more likely that they will suffer from chronic diseases. Who, then, will take care of them?
That is true. But even though women tend to live longer, this greater life expectancy does not necessarily mean that they will enjoy good health. In some European countries, there are twice as many elderly women as men. Even in the country with the least difference between women and men’s life expectancies, there are 50% more elderly women. This difference implies a much higher proportion of women as health consumers, especially in the case of chronic diseases.
On a lighter note, as I recently joked in the course I taught in Chile, men tend to die handsome, rich and happy, because they die at a younger age and are less spent physically; they die rich (or at least, not as poor), because they have better retirement funds which they themselves control; and they die happy because, due to cultural norms, their first marriage is to women who are younger than they are and their second marriage to women who are much younger. Thus, this age differential serves as a guarantee that they will be cared for and pampered during their old age. Perhaps these kinds of generalizations sound exaggerated, but they are often true.
What happens to the women?
All women know that towards the end, they will likely be faced with some ten years of life without a companion because on average they marry men who are four or five years older then they are and because the men tend to die before they do. They also know that they will have to face old age and death alone, in a state of physical deterioration and with less economic security.
How has the issue of maternity leave for taking care of young children been resolved in your country, Spain? In other countries, such as Chile, this issue has become a controversial topic, especially since some sectors criticize the supposed “abuse” of this leave.
In Spain, long leaves of absence are granted for this reason. Two years ago, our legislature passed a law calling for the reconciliation of family life and work, and it is quite novel because it grants both men and women equal rights to social benefits and leave…not only for taking care of younger children, but for caring for any family member. This is of particular importance in our country where there are more problems with providing care for older family members than for young children. Care of young children is cheaper and requires fewer years than care of the elderly. The problem is that the budget for some of these benefits is minimal, and the number of services offered has not grown. Even more importantly, men in our culture are not being socialized to exercise this right, or this obligation, to share in the responsibility of caring for children and others. As a result, it is likely that the women will be the ones who continue to take leaves of absence for caregiving.
On the other hand, since the salaries of men tend to be higher, there is less of an economic impact on the family if the salary of the woman wage-earner has to be sacrificed. But the interesting thing is that the law of reconciliation reflects a change of perspective, recognizing for the first time the political value of men and women’s equal responsibilities with respect to health care. At the same time, the care of the elderly, and not just of children, has now become a political priority. Even though this law is not often exercised, these are very interesting changes.
Health is a crucial issue in today’s societies, both in developed and undeveloped countries.
Of course. Health is the cornerstone of any system or social structure. It proves that a society can really become what it wants to believe that it is. In this sense, along with immigration, the issue of the health care for the elderly is the greatest social challenge that we are confronting in Europe.
In this century, we are also witnessing the consequences of the rupture of a social contract based upon the assumption of women’s inferiority that has been in place for thousands of years. According to this contract, the division of roles is based on the idea that women are inferior to their husbands and should obey them. Therefore, women’s access to education, their autonomy and reproductive rights are both a consequence as well as cause of the recognition of equality between men and women and people’s freedom to make their own decisions related to marriage, the number of children they wish to have, access to the labor market, etc. These are some very revolutionary changes, and we still have not fully comprehended what they will mean.
RELATED ARTICLE: Women’s Role in Health Care
1. Health promotion within the home:
a) The creation of conditions that promote health;
b) Provision of preventive health care;
c) Home care for the ill;
d) Care for the chronically ill or disabled;
e) Home care for the terminally ill who are excluded from the healthcare system.
2. Health promotion within the health-care system:
a) Mediation with the health-care system;
b) Participation in the health-care system as health-care professionals;
c) Other forms of participation in the health-care system.
3. Rituals of transition:
a) Care for the dying;
b) Participation in the rituals of death; redistribution of family responsibilities and roles.
4. Demand for health care:
a) Participation as patients/clients/users; illness and health; women’s perception of their own health.
Source: Adapted from the chart “El papel de las mujeres en el sistema global de cuidado de la salud,” in Maria Angeles Duran, De puertas adentro. Serie Estudios 12. Madrid: Ministerio de Cultura/Instituto de la Mujer, 1988.
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