Based in Marseille, Spina is a journalist, writer, and the founder of media outlet Manifesto XXI. He is the author of Manifeste pour une démocratie déviante: Amours queer face au fascisme [Manifesto for a deviant democracy: Queer love in the face of fascism; éditions trouble, 2023, untranslated], in which he proposes pathways to resistance rooted in the radical power of tenderness and care.

In the below essay, of which a version was originally published in his newsletter, he examines care and its practices in light of his own experience of vulnerability, in the perspective of a left that would make true space for all lives and all bodies.

In 2022, a degenerative disease — scleroderma — upended my life. The following year, after an unexpected heart transplant, I found myself living with a disability. This pushed me to rethink my life and make significant decisions: I reconfigured some of my relationships, left a job that had become unbearable.

During my hospital stays, sharing daily life with other “fractured” bodies, I noticed the lack of solidarity networks — within my own circle and certain queer communities but also in public spaces.

I encountered a form of inhumanity that deeply shook me. In activist circles, even those claiming to be left-wing, I violently felt the gaze that reduced me not to a living, thinking, loving subject, but to a disabled body, a burden, almost unworthy. More than the illness itself, it was this ableist dehumanisation, sometimes well-intentioned but always brutal and controlling, that traumatised me.

The sense of existing halfway between life and death does not come solely from my transplanted heart, but from the way the social fabric around me stripped me of any legitimacy to fully exist within the spaces that were once mine. Day after day, my mental health deteriorated. I faced severe burnout, followed by medicated psychiatric care.

What I am going through — physical pain, fatigue, loneliness — is a profoundly widespread and shared experience. As the months passed, I discovered that while unique in some ways, my journey resonated with that of many others; including people with whom I would never have imagined forming connections. I met elderly people, isolated patients, activists from diverse political backgrounds, all united by the same ontological vulnerability.

Yet despite this undeniable reality, everything unfolds as if vulnerability always belonged to someone else. An unbounded hubris leads us to believe we will never find ourselves in that position. “Your able bodies are ephemeral,” chant the anti-ableist, feminist, and queer collective Les Dévalideuses1. This structural lack of empathy is entirely contradictory to any attempt to embody left-wing ideals.

For years, I had been passionately interested in the ethics of care and love as a political force. Nothing suggested I would be marked in my own flesh by the experience of permanent physical vulnerability. This experience pushed me to reassess the ableist bias through which I had viewed the world until the age of twenty-seven.

For while the transplant and disability transformed my daily life, they also offered me a new understanding of the fragilities many encounter — whether physical, psychological, social, or economic. During my lengthy stays at the clinic, including a month-long hospitalisation following the 2024 legislative elections, I had time to reflect on the left, its obstacles, and these essential questions:

Why does the left struggle to find its place within the ultra-liberal democracies of the West? Have fundamental mistakes been made in assessing the contemporary cultural landscape? Why do we fail to offer a compelling existential vision to many voters? What do our representatives lack to convey a message capable of convincing? How can the left reconnect with the realm of emotions to propose unifying and emancipatory perspectives, and thus inhabit differently the fears and feelings of abandonment that the far-right exploits?

As I explored in Manifeste pour une démocratie déviante, the far-right promises to eradicate insecurity and isolation while fuelling them. The ‘capitalocene’ — a term proposed by Italian essayist Marco Bersani2, which I prefer to that of ‘anthropocene’ to specifically designate the capitalist era — perpetuates this pandemic of loneliness by imposing a fragmented, primaverist3 temporality. This vicious cycle feeds on the very fragility it creates.

One possible path to overcoming the deadlocks of contemporary resistance lies in organisations rooted in care and an ethics of vulnerability. Political scientist Joan Tronto, a pioneer in care studies, defines care as the set of gestures, attentions, and practices that enable us to “maintain, perpetuate and repair our world”: our bodies, our relationships, our environments4. It is a collective effort to support everything on which life depends.

In the continuity of this thought, sociologist Judith Butler approaches vulnerability not as a marginal or shameful state, but as central to life itself. To be vulnerable is to be exposed to others, affected by them, dependent on material, emotional, and social support networks. Primarily corporeal, this exposure is also political: certain bodies and lives are made more vulnerable by social, economic, and racial structures that determine who deserves protection, care, or compassion5. To recognise this shared vulnerability is to found an ethics and politics of solidarity.

The precarity we experience throughout our lives, which I have felt in my own body, thus stems less from our physical conditions than from how society chooses to ignore or marginalise them. It is through the work of a long genealogy of queer, crip, and feminist thought that I have begun to accept and love this revolutionised life.

Anti-ableist author Alison Kafer defines ‘crip studies’ as a militant and theoretical field emerging from ‘disability studies’, which challenges social norms related to the body, autonomy, productivity, and validity. The term ‘crip’ — originally a slur derived from ‘cripple’ — is here politically reclaimed to describe ways of living and knowing that subvert an ableist order.

These studies draw on the experience of disability and illness to imagine new ways of inhabiting the world, valuing interdependence, slowed temporalities, care relationships, margins, and bodily dissidence. The aim is not to add disability to a list of oppressions, but to radically critique what society expects from a ‘normal’, capable, and performing body.

For the left to be more than a mere circle of belonging, it must once again become a proposal for evolving ecosystems. I advocate for a social movement that transports us into a new era, regardless of how long it takes. In this sense, the ethics of care (which align with the concept of romantic revolution I discuss in my first essay) and crip studies offer powerful levers for renewal.

Sometimes adopting harsh methods, akin to neo-populisms, the so-called ‘radical’ left seems trapped in a logic of confrontation that stokes tensions and fuels ambiguity with the very hierarchies it claims to oppose: vertical and patriarchal power relations, polemical use of social media, militant purity, purges, attacks on mental health, whiteness, ableism. The left in Europe struggles to make itself heard. It appears more focused on rhetorical techniques than on the strength of its vision and embodiment.

Yet, capitalism as an anthropological phenomenon is not merely an economic system: it is also a culture, an imaginary, a way of being in the world that is consubstantial with fascism. It permeates behaviours, shapes affects, transcends partisan divides, and defines who we are far beyond our political affiliations. Being ‘radically left-wing’ is therefore not enough to avoid being ‘capitalocentric’ — primarily concerned with the pursuit of social, material, erotic, reputational, and other forms of capital.

If we move beyond the narrow framework of mere political advocacy, often devoid of concrete embodiment, what does it still mean to ‘be on the left’ in our daily actions, our relationship to power, to the collective, to otherness? Even if we momentarily set aside the quest for power, what does it mean to practise and choose ‘the left’ every day as an ontological horizon?

The left today has a precious opportunity to enter a fertile phase of reinvention, where it could rethink its promises, representations, and the political alternative it offers in the face of the right.

This vision, extending my work on love as a social force, materialises in the construction of a ‘care society’, which would shift the centre of gravity of our priorities from economic performance to care relationships — and the professions that make them possible, often performed by marginalised individuals.

Like many, I see the rise of fascism, the genocidal wars waged with near impunity, the increase in social precarity. Yet, I feel the need to go beyond a stance of mere opposition to the far-right. The role of the left, I believe, is to open up horizons, to imagine an alternative social project, a world where life and its transmission would be fully possible. It is about accompanying a lasting transformation rather than a revolution that goes in circles — the literal meaning of the word ‘revolution’ implying something circular and repetitive. The left must be capable, even within its own ranks, of denouncing the powers in place and the deadly logics they perpetuate.

This echoes the critiques levelled by communist filmmaker and writer Pier Paolo Pasolini against the Italian left of the 1950s, which he accused of betraying the working classes by allying itself with the establishment. He denounced its bourgeoisification, its proximity to Christian Democracy, and its failure to truly transform the nation after fascism. Later, in his Scritti corsari (1975), the intellectual lambasted a left incapable, in his view, of understanding new forms of power — particularly consumerism, which he saw as a tentacular and impalpable totalitarian force. For him, fascism had never been as fertile as under the Republic, within which it became institutionalised and definitively normalised.

Politics is often the ambition of domination — the imposition of certain values and ways of living on others, with or without their consent. It is, in other words, the struggle to hold the monopoly of the norm. Communist philosopher Antonio Gramsci spoke of cultural hegemony. This goes beyond a simple ‘quest for power’, which is not in itself necessarily harmful: in the word ‘power’ also lie deeply vital values, the power to be, the power to do, as activist Starhawk writes.

And what, ultimately, is the role of the radical left, if not to detect all forms of domination, even the most insidious?

Vulnerability is an experience inherent to earthly existence, affecting each of us at different times. I deeply believe in its unifying power. Similarly, care is too often reduced to a soft aesthetic or an individual sympathetic behaviour. Instead, it should be conceived as a principle of collective organisation, a social architecture in its own right.

I would like a left that places these questions of vulnerability, care, and horizontal relationships at its core. An anti-ableist and anti-racist left, which would enable us to reflect on what, in our society, is considered fully human.

To think about the left and care is to question the presence or absence of death in our habitats. To contemplate mourning, to analyse how we hierarchise existences, render some deaths invisible, and mourn others. These burning questions permeate current events, where thousands of lives are erased in a chilling media normality.

Philosophers like Myriam Bahaffou propose moving beyond the humanist framework, so that we no longer have to measure the value of life through a utilitarian lens6. Instead, we should adopt a molecular vision of our political models, as imagined by Italian botanist Stefano Mancuso with his ‘plant democracy’. A society rooted in an underground, indestructible fabric because it is self-regenerating, nourished by attention and connections. The time is ripe for a political discourse that places all living beings, in their diversity, at the centre — far from the necropolitics of the far-right and the blind spots of the left.

Care allows us to rethink the left in its existential dimension, as a set of movements aimed, above all, at granting all lives the dignity of being lived and all deaths the dignity of being mourned.

I do not claim to open and close the subject of the left’s re-enchantment; simply to contribute a small stone to its edifice. What I sketch here is largely an invitation to widen the imagination, but many others work to craft concrete solutions that bring these principles into reality. One just has to be willing to look for them7.

The challenge is to make our struggles exist beyond the reductive logic of the conquest of power, turning away from regressive dreams of domination. Redesigning the left, its ambitions, its political programmes; enriching its methods of action, meditating on its very essence and how to embody it. Envisioning other forms of presence, other ways of inhabiting this world — other ways of fighting, together.

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Caregiving is often posed as the last bastion of life that should remain untouched by technology. Even traditionally tech-friendly news outlets are routinely concerned with the impact of AI and automation on our medical and interpersonal care systems:

The Economist: How AI is rewiring childhood
The Economist: Millions are turning to AI for therapy
The FT: Why your AI companion is not your friend
BBC: Is this the year domestic robots come into our homes?

Many see the application of technology to care as cold, sterile and removed of the essential humanity that care requires. But is this intrinsically true? Are technology and care truly incompatible, or is it our applications that need figuring out?

My master’s degree is in computer science, and my thesis was in the field of human-computer interaction (HCI). HCI is a multi-disciplinary area which studies how people interact with digital technologies in order to make those interactions useful, adequate, meaningful, and ethical. I focused on building play technologies – think interactive toys – to encourage social play in mixed groups of neurodiverse and neurotypical children. Play is essential for early development, but autistic children are often excluded from social play groups due to differences in social and communication preferences. Building the right kinds of toys can facilitate social play within groups, leading to more positive play interactions for all children.

An uneasy pairing
Technology is pervasive throughout caregiving: from toys for children and baby monitors to telephones and personal alarms (which detect falls or shaking motions and help access emergency care) as well as medical technology (x-rays, MRIs, ultrasounds) and accessibility tech (wheelchairs, hearing aids, prosthetics, and in the near future, self-driving cars). We use technology to extend human capacity and reduce unnecessary suffering, but also to facilitate connection where physical restraints preclude it. A loved one can be on the other side of the world, hard of hearing, or still inside the womb, and technology can help to connect us.

Despite this long history of compatibility, the addition of modern technologies to social wellbeing and care solutions often feels deeply uncomfortable. Even as someone who has spent time researching and building in this field, I feel a persistent unease when reading headlines about AI in schools, robots in houses, or surveillance technologies introduced into care homes for older people.

This discomfort reflects more than a fear of novelty. Instead, it points to an underlying awareness that modern societies are already struggling to provide care in ways that feel sufficiently humane and relational. We intuitively perceive that technology is being introduced not to deepen care, but to compensate for its absence. Care systems are overstretched, so technological solutions act as substitutes for true time and presence.

Maternal care is one such system. Modern obstetric technologies such as continuous fœtal monitoring have undoubtedly saved countless lives and remain essential in high-risk situations. Yet their routine and sometimes unnecessary application has also led to significant harm1. Over-medicalising a typically healthy physiological process tends to reduce the autonomy of those giving birth2, and marginalise midwifery and community-based birth practices. It is not surprising, then, that many people working at the frontiers of obstetrics respond by calling for a return to older or “lostˮ practises, forms of care grounded in community or embodied knowledge built up through generations of human experience. Yet once again, while the majority of women who have doula-assisted or home births feel empowered by the experience, a more extreme though fringe tendency to reject modernity altogether can have fatal consequences.

Similarly, the recent use of AI to address pervasive loneliness in society feels disturbingly miscalculated. The concern many of us experience when confronted with AI companions, chatbots designed for emotional support, or “friendshipˮ technologies that provide artificial intimacy stems from a recognition that these are being positioned as remedies for structural failures rather than as complements to a healthy social life. They fail to distinguish between supporting care and overriding it. If our patterns of work, urban design, digital use, and economic incentives have produced widespread isolation, fracturing communities and leaving people with little time or energy for relationships, introducing artificial companions merely risks compounding this harm.

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Money is of course a big factor here. It is much cheaper to offer someone a chatbot than to hire a care professional; and unlike relational care therapies, one can get very wealthy selling tech solutions. Technological tools facilitate the privatisation of care, allowing the state to outsource part of its responsibilities. This can be a good thing, enabling national institutions like the UK’s NHS to access ground-breaking treatment technologies they would not have had the capacity to develop themselves. For example, FLOW headsets used to treat treatment-resistant depression through stimulation of specific brain regions have shown really promising results, and are now used by the NHS in a number of areas. However, private companies’ growth imperative means they often need to continuously push these tools towards new users, even those who would be better served by relational therapies.

Like other societal failures of care, mental illness and loneliness at scale are the outcome of decades of policy choices and cultural shifts. Addressing them meaningfully will require slow, contested, and deeply political changes, along with significant investment whose returns will not be visible within one electoral cycle. Technological solutions, by contrast, can be developed and scaled rapidly by a small number of people. They offer the appearance of action without demanding structural change, and in doing so risk us dismissing loneliness as an individual condition rather than a collective failure. By investing in a technology, a company or government can say, “We are actively working to tackle loneliness and improve mental health” without actually having to make any difficult decisions or long-term changes. This is easy to see in the workplace, where companies will buy a subscription to apps like Headspace in the name of protecting employee wellbeing, without addressing the structural issues contributing to stress and burnout. We are adding plant food and hoping to see flowers bloom, while the roots continue to rot beneath the surface. Without looking at the underlying conditions that sustain human connection, technological interventions risk producing superficial growth while accelerating the decay below.

Given this, it might seem like the inclusion of tech in the future of care is exclusively problematic. Yet the benefits touched on above remain real, and there are constructive ways to harness them. To understand what a more balanced approach could look like, I spoke to Elaine Czech and Rachel Keys, two researchers from the BIG (Bristol Interaction Group) lab, which works to improve peopleʼs lives through the design and study of technology.

To trust or not to trust your smart watch
Rachelʼs motivations to work in HCI began as deeply personal. Her husband became unwell with a heart condition that doctors would not take seriously. Through a wearable device (think smart watches), he was able to gather data and use it as evidence that further investigation was needed. He was eventually rushed to hospital for treatment.

Following this experience, Rachel chose to do her PhD research on the use of wearables in the diagnosis and support of people with heart conditions. She has lived experience of the fact that technology can provide invaluable data that allows people to access the appropriate care. This has been particularly important for women and minority groups, whose self-reported symptoms are still not taken as seriously by medical professionals. Women’s health has historically been shockingly underresearched3, and the widespread use of digital trackers is helping to address this imbalance faster than the medical research community could do alone4.

These tools allow users to conduct long-term research on themselves, tracking symptoms over months and years. This, Rachel pointed out, is especially useful for women whose hormonal changes mean symptoms can appear over the course of many months, and present atypically. Wearables allow people to see what their “normalˮ is and track detailed information over extended periods of time. For women with POTS and long Covid, wearable-generated data can offer especially meaningful insights.

Here, technology helps people advocate for themselves and receive support tailored to their needs, without medical practitioners making potentially biased assumptions about which categories they fall into. We shouldn’t be in a situation where many people still have to fight for their symptoms to be taken seriously – but seeing as we are, we should make use of the tools we now have at our disposal as part of the push for substantial change.

The major downside at the moment, Rachel explained, is that “health care professionals donʼt know whether to trust the dataˮ. Wearables often cannot market themselves as medical devices, which would subject them to different product legislation – so they call themselves “wellnessˮ devices. They often function as black boxes, meaning we donʼt know exactly how the data is being collected and processed, and therefore struggle to assess the quality of the measurements. “It puts doctors in difficult situations, because the data is so medicalised that they feel they have to act on it. Research coming out of the US is showing that wearables lead to excess use of medical resources and over-intervention5”. We are all naturally concerned with our health – but having access to a constant feed of information risks encouraging us to needlessly investigate perfectly normal variations.

Building with those we are building for
Elaine Czech’s research currently focuses on building tools for people with Parkinsonʼs. She has been designing a study that uses a wearable device triangulated with home cameras to monitor the progression of the disease over time. We spoke about the importance of people working in HCI acting as “translatorsˮ between the engineers and end users.

“End users can’t necessarily articulate what they want really clearly or in computer science terms”, she explained, “and so the engineers are stuckˮ. Translators are therefore vital in making sure that the needs of caregivers and care receivers are heard, while mitigating expectations of what a technology can truly deliver. Elaine emphasised the importance of engineers and researchers beginning to look at “care ecosystemsˮ. Care is, at its core, relational: it is never received or delivered in isolation. Yet most research is still focused on solutions for individuals. Elaine is lobbying for more research on dyads – mostly couples. Her research mainly centres on older people living with long-term health conditions, most of whom live with a partner, so any technological support needs to work for both people. Like physical spaces, care technology must be designed to center interpersonal exchange.

Giving people agency in the kinds of technologies available to them is an essential step towards this goal. Part of my own research focused on the importance of including the people you are building for as an essential part of the design process. In developing toys for social play, we designed activities that encourage children to come up with games that get everyone involved, including people with specific sensory or social preferences. These game designs were then used as foundational in the technology design phase. Co-design values lived experience alongside technical and design expertise, and involves actively listening to care recipients and practitioners to understand the heart of their concerns. As such, it stands a much better chance of addressing the root causes of failures of care.

To achieve co-design at scale, various groups need to be willing to participate in research and work with developers. This highlights another barrier researchers face: participation. Researchers fight an uphill battle in recruiting participants for studies. In the UK, one of the best ways to recruit from a diverse pool of people is to get NHS ethics approval, which allows you to advertise your study through hospitals and GP practices, and lends reassurance to wary volunteers. However, many researchers wonʼt even apply for NHS ethics because the approval process takes too long – up to 18 months, which on a 3-year PhD program, just isn’t viable. If we are going to build technologies that really work for the people who need them, we need to change the systems that prohibit this research from happening.

People also need to be willing to partake. It is a big ask to open your life up to potentially invasive research with no promise that it will be successful. This is further hampered by a history of unethical research programmes: Elaine pointed to the Tuskegee syphilis study, a shocking example of medical malpractice where known treatments were purposefully withheld from 400 African-American men with syphilis in order to observe the progression of the disease6. More than a hundred of them died as a result.

Stay in your lane
In many ways, our discomfort with the application of technology to care is less about the tools themselves than about what they reveal. The use of tech functions as a microcosm for our systems at large, making visible the absences and inequities already present in them. At its worst, tech can be used to dehumanise, isolate, over-intervene, and mask serious flaws in our delivery of care. At its best, it allows people to gain back their autonomy, and provides life-saving information or intervention.

The main issue seems to be a lack of what we could call ‘technological humility’. Tech enthusiasts are famously very good at claiming that tech will overtake our lives and solve all of our problems, and very bad at admitting that it makes some of the latter hopelessly worse. A welcome example of humility came from Arthur Mensch, the founder of Mistral, France’s AI giant. At a conference given last month to students of the country’s top engineering school, he said:

« We don’t believe in the techno-solutionism that seems to prevail on the US West Coast, which consists in thinking that all the world’s problems will be solved by artificial general intelligence. (…) It will not solve climate change — it objectively tends to make it worse — and it won’t solve our issues with care, with contact, with our ageing populations. There is an entire class of care and relational jobs where AI only has a minor role to play. »

Such pragmatism is refreshing. For tech to work in care, it has to accept being a supportive background player, instead of trying to take over the entire field. Public care systems need leadership that is extremely clear-eyed about the limitations of technological tools, and extremely ambitious about investing in people. That means higher salaries, better working conditions, more relational training, improved communication between designers and end users, and reduced barriers to essential research. It could also mean radical measures: France’s national agency for the social economy recommends the exclusive delegation of all care activities to the state and to mission-oriented private companies by 20507. Paradoxically, by bringing our failures to light, the technological revolution might be the very thing that forces us to confront what good care truly requires.

This week, I am sharing this beautiful, if alarming, text by Rebecca Mack – who writes the newsletter ‘This Woman’s Work’.

The impetus behind The Fifth Wave came partly as a result of my reading ‘Of Woman Born: Motherhood as Experience and Institution’, by Adrienne Rich, sitting on the steps of the Bodleian Library during my last few days in Oxford.

Reading that book, and diving into the world of thought that subsequently revealed itself to me, was probably one of the single richest intellectual experiences I’d had up until that point. In it, drawing on extensive research as well as her personal experience in her first heterosexual marriage and then as a lesbian mother, Rich picks apart how the figure of the mother – imagined, fantasised, imposed, enforced, all but defined by its actual embodied experience – has for millennia been a central tool of the subjugation of women.

In the below, Rebecca writes of her experience as a midwife in the UK’s NHS, and the systemic failures that ultimately led her to seek a different way to care for women. I’m sharing it here (it has been slightly edited) because it deeply resonates with the Institute’s vision for a different, care-centered world. It also feels appropriate as C-section rates have recently surpassed those of vaginal births in England.

Both this essay and ‘Of Woman Born’ exemplify two of our deeply held beliefs: our systems are broken, and they can be rebuilt. “The fields need to be radically dug up and new ones sown”, as Rebecca puts it – in midwifery as in all other spheres of human activity that involve people taking care of each other.

As Rich writes in her 1977 essay of the same name,

“We need to imagine a world in which every woman is the presiding genius of her own body. In such a world, women will truly create life, bring forth not only children (if we choose) but the visions, and the thinking necessary to sustain, console, and alter human existence — a new relationship to the universe. Sexuality, politics, intelligence, power, motherhood, work, community, intimacy, will develop new meanings; thinking itself will be transformed.

This is where we have to begin.”

I came late to midwifery. I was twenty-seven, earning 25K a year as Personal Assistant to a group of corporate directors. Free gym, nice offices, lovely boss. It wasn’t enough. I had a calling. Possibly a catholic or middle daughter thing, I don’t know – I just knew I wanted to help people.

Midwifery looked like the perfect job: women-centred, empowering work and oodles of babies to cuddle. Whilst training, I did a two-week placement on a special care baby unit where my main job was to sit, skin-to-skin-cuddling preemie babies in my cleavage. After the two weeks ended, they practically had to escort me off the ward. It was joyous.

I knew instantly at my university interview that this was the career – or rather, the place for me. Not long after, I was called back to the office of the midwifery lecturer who had just interviewed me. She sat at her desk, swinging on her chair, shoes off, chatting animatedly to her colleague who was curled up on the sofa. ‘I’m home’, I thought. ‘I want to stay in this world forever.’

The training lasted 3 years and was hard going from the start. We spent half the week working on the wards and the other half studying in classrooms. There were no long holidays like other students and if you missed a shift, even due to illness, you were required to make up the hours in your own time – meaning most ‘holidays’ were spent back on the wards. We were paid a small bursary (not meant for anyone to live on) which has since been terminated for new cohorts. The real payment came in the satisfaction of learning and experiencing the craft you loved.

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Lovestruck I was. Many a time, I walked on air as I bounced home, remembering the beautiful newborn that had just been miraculously pushed into my hands. But as time progressed, I missed – or ignored – the emerging red flags.

The wards were permanently short staffed. By the second year, I found myself being used as ‘staff’ instead of ‘student’ in low-risk areas. ‘Breaks’ on an eight- or twelve-hour shift were a luxury, not an essential. A quick dash to the loo whilst running in between patients and finding sustenance from the ‘thank you’ chocolates left in reception became the norm.

Shifts never ended on time – typically due to a lack of staff to hand over to. The fear of litigation loomed large, and practice often felt more ‘defensive’ than ‘responsive’. The constant requirement for documentation interrupted the flow of organic relationship building and care providing.

As students, we were shielded to an extent from the negative sides of midwifery. Kind mentors would insist we take a break or encourage us to go home before our legs gave way. Unqualified, we were free from the threat of losing our registration, and we could spend time building relationships with our women and their families instead of documenting our every breath. Alas, we would not remain students forever.

With the thrill of qualification came the terrifying removal of the protective mentor’s shield. Caring for women and their families was still the ultimate high for me; but unfortunately, the anxiety around their safety – and my sanity – became the ultimate low. The system wore me down, not the people I cared for. The lack of staff, the overcrowded wards, the constant life-threatening juggling act. I was permanently anxious. I would frequently leave a shift exhausted, back literally breaking, bladder bursting and spirit just a tiny bit more broken.

The unpredictability of each shift terrified me. I can remember starting a night shift on the postnatal ward, being moved to the antenatal ward – while still caring for my postnatal charges – and then delivering one of my antenatal women on labour ward. After 14 long hours with no break, I emerged from the delivery room with a fresh newborn wrapped around my neck, begging to go home to my own children.

Yet barely through the door home, I was back on the phone. ‘Has that baby in bed 3 fed yet?’, ‘Can someone check the CTG on the woman in bed 6?’. My husband removed my shoes, I drank a longed-for cup of tea, then another, and then another.

This was not the exception but the accepted rule. I would have loved to spend that night providing life-changing care to all those women and babies. Instead, I was gasping for air just trying to keep everyone safe. Too many women, too many babies, not enough staff.

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The professional cost of giving the ‘bare bones’ of care was a constant source of frustration and anger to me. Job dissatisfaction corrodes morale. I have a friend who is a decorator. He painted my living room last year. He is a perfectionist, prides himself on his smooth finishes and straight lines. He offers sage advice when I get carried away with clashing colours and he leaves every house he paints a better place to live. Each job he completes fires him up for the next. He is proud to show his customers his work.

Imagine if he was a midwife. ‘I’ve slapped some colour on the walls – if you squint a bit, you can’t see the dodgy lines; sorry I didn’t get a chance to do the skirting boards, you can hide them with the furniture; didn’t do the ceiling but it’s not so bad, just try not to look up. Anyway, got to go, didn’t want to say but I’ve been decorating two other houses at the same time, and I’ve not finished them either.’

It would be demoralising, embarrassing, sad. Not what he trained for.

During my last shift, I attended to a distraught mum as she delivered a 20-week-old, much-wanted baby in the maternity reception bathroom. The desperate mum was waiting for a bed. There were no beds. And not enough midwives to staff one even if one was available. It was 3 a.m. in the morning. Ten years from that inspiring interview and seven years on since qualification, I was done.

Sadly, I was not alone. Approximately one-third of my cohort of 30 had left the profession by the time I hung up my stethoscope. Some stayed within the NHS (I did). Some could not get far enough away and went into other roles, as diverse as overseas property management and cake making.

The solution appears simple – hire more midwives. But like me, so many just would not go back, and so many newly qualified just will not stay. Changing the landscape of midwifery goes far deeper than throwing more hands into the fields. The fields need to be radically dug up and a new fresh and women-centred field sown.

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Answer me this… would midwifery be in this dire a state if men gave birth? I can’t see that men would be expected to tolerate a maternity system that struggles to provide safe, never mind (don’t make me laugh), holistic care if they were the pregnant ones.

The way we treat our pregnant, labouring and postpartum women is a tragic indictment of the way society too often treats women, and mothers in particular. Second-class, disposable, put up and shut up, vessels for male folly, unworthy of care. That women and their bodies don’t matter is no more evident than in maternity wards worldwide.

My love affair with midwifery will never end. I can’t go back to the trauma of the wards, but I can’t completely walk away either. My passion for the care of women is still as unshakable and necessary as it ever was, if not more so. Grassroots change is needed, and my pen is mightier than my stethoscope at this point.

So, I sit here, shoeless, swinging on my chair, animatedly chatting to Substack, writing about midwifery, misogyny, mental health, and more. Advocating for women, for mothers, for families. I never wanted to leave midwifery; midwifery is my home. I cannot deliver babies anymore, but I am working on delivering the truth about the treatment of women and mothers. I would love for you to join me.

The term ‘institutional care’ is an ambiguous one. On the one hand, it can simply refer to care in institutions, i.e., organisations and spaces that formally structure the provision of care to specific groups of people: nursing homes, daycares, hospitals, maternity wards, at-home healthcare services.

But another, pejorative association refers to orphanages — or, according to British charity Hopes and Homes for Children, “residential facilities for large groups of children” characterised by a one-size-fits all approach, depersonalisation, rampant sexual abuse, lack of privacy, disempowerment, and social isolation. This is not what this piece is about.

However, one sentence in Hopes and Homes for Children’s explanatory article struck me: “‘Institutional care’ is an oxymoron – institutions cannot by definition care”.

Putting aside the specific context of HHC’s mission, that sentence sums up much of the current sentiment around the organisation of caregiving in modern societies. Formal structures and institutions are often synonymous with chopping up family life, breaking up communities, and compartmentalising society into neat categories. Eldercare on one side, daycare on the other. Work is work, family is family, and the two can’t interact. Parenting is a private thing to be managed by the parents alone, and “kid-free” cafés ensure that people who dislike children can opt out of interacting with them (apparently even in places originally designed for kids).

The various industries in the care sector are plagued by headline after headline showing how privatisation, optimisation and compartmentalisation produce hyper-strained systems with dangerous if not outright life-threatening failures of care. See Australia’s scandals over private aged care, childcare and acute hospitals, or French journalist Victor Castanet’s two investigative books that respectively exposed the country’s private eldercare then private childcare corporate monoliths. It’s fairly evident by now that caregiving and private equity do not tend to make for great bedfellows. In many countries, childcare is even described as an outright market failure.

None of that girly stuff

This tension has deep roots. With a feminist lens, the history of economic, social and cultural change over the past five hundred years can be broadly understood as the manufactured separation of worlds and their reconstruction as opposites: public versus private; the medical versus the embodied; masculine versus feminine; adult from child; ‘rational’ from ‘emotional’; the industrial from the natural. And in those artificial separations are of course hierarchies: the public, the medical, the male, the adult, the ‘rational’, the industrial: we could call that the Tier 1 world, i.e. the serious world, the real world, the economically valuable world, the productive world. The rest – the private, the human, the female, the child, the emotional, nature, all of which caregiving is associated with – is Tier 2. Secondary, less worthy of attention, of policymaking, of academic study.

For something like caregiving, the process of bringing it from the private Tier 2 sphere to the public Tier 1 world by formalising it into institutions therefore often means stripping it of its pesky Tier 2 attributes: empathy, feelings, human connection. What matters is keeping its technical, ‘logical’, ‘rational’ (heavy on the quotes here) aspects, central to well-functioning economic systems. The rest is fluff.

In practice, this looks like care systems prioritising medical and sanitary outcomes over meaningful human connection and emotional well-being, which get relegated to mere add-ons instead of central KPIs. The history of the institutionalisation of care is rife with iterations of this, with the medicalisation of childbirth through the exclusion of (Tier 2) midwives by (Tier 1) male doctors being perhaps the most well-documented example with the most dire consequences for mothers. More recent ‘innovations’ like task-based pricing in hospitals incentivise the optimisation of each technical procedure at the expense of the equally vital moments of interaction between patients and staff. Compassionate explanation, connection and reassurance get squeezed in between bloodwork and surgery - leading to worse health outcomes, lower patient satisfaction and higher rates of medical staff burnout.

This status quo can be summarised by ’s formula of ‘minimum viable care’: “a system designed to sustain just enough care from just enough caregivers, [which] prioritises maximum efficiency and minimum surplus, [stripping] dignity and stability from both labor and consumers.”1

The tendency to formalise things by segmenting them is not unique to systems of care. It's also not necessarily harmful: it can make some things work much better. But unlike automobile assembly lines or management consulting, caregiving suffers especially from compartmentalisation. Because the connection, the empathy, the deeply intimate… are kind of the whole thing. That’s what care is. Care is what makes the self relational - it’s the antithesis of separation. It is interdependence. A hand held out. A stranger offering to hold your baby. An Auntie spending time with children who aren’t her own. Care is about the process of human connection much more than about measurable outcomes. So when you strip that, well, you basically strip care altogether.

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To the forest we go

In the face of all this, some are tempted to just do away with formal care institutions. It can seem that, since institutions are bound to be compartmentalised, and compartmentalisation acts on care like Roundup on a patch of green grass, institutions indeed “cannot by definition care”. Care can never be healthily coupled with any kind of profit-making, daycare is cruel, and putting one’s parents in a nursing home is inhumane. Away with all that, let’s have exclusively natural, home births, reject modern medical systems, and go raise our children on feminist communes in the woods.

I’m obviously being caricatural here. Efforts to strengthen community life, re-build ‘the village’ and recreate conditions akin to that of small-scale societies are extremely valuable. But even those typically require a lot of intentional thinking and concrete action, in order to build structural conditions that allow for spontaneous and collective care to take place. Complete withdrawal from organised care is almost never an option, and it also does not scale well into systemic solutions.

This becomes very obvious when comparing the state of public policy discourse around care in different countries: in places with existing universal support systems, public opinion is often focused on pointing out their inadequacies, but in countries like the US, many parents and caregivers are desperately begging for the implementation of formal structures to help relieve the pressure off of individuals.

This is the institutional paradox of care: the same structures that make care institutions deeply flawed also make them absolutely essential to well-functioning modern societies. Faced with this paradox, it often seems we have a binary choice: we can either completely disengage from formal structures to preserve the spontaneous and organic nature of care (but as I said, that’s only an option for a very select few), or ‘give in’ to institutions that inevitably strip it of its relational essence.

But reality isn’t binary, and when we step out of manichean frameworks, we see that formal care structures don’t have to be (and so many aren’t!) soulless vessels we’re just forced into by modernity for lack of viable, organic alternatives. When built correctly, they can also be places of beautiful connection and joy, allow caregivers to pursue meaning in other ways, and help shift some of the heavy responsibility that interdependence tends to place on women to keep communities thriving. Institutions can help ensure that a greater number of people get adequate levels of care without relying exclusively on the sometimes fluctuating goodwill of family members.

So how do we overcome the paradox? How do we formalise care in a way that provides much-needed structure to social life and relief for caregivers, without manufacturing disconnection? As often, the boring, nuanced answer is the most promising one: it’s all about compromise. Not opting out of institutions entirely, but building ones that leave enough space for the natural porousness of care to freely manifest. Ones that institutionalise fluidity.

This isn’t to say that everyone should have to opt in to institutions – there should also be substantial support, resources and recognition for those who want to give birth at home, stay home with their kids in the first few years and live with their ageing parents to support them in late life. But institutional alternatives that preserve the essence of care should be widely available for those who need them.

Building the futures of care institutions

One strategy involves making existing institutions and spaces more porous through external intervention – like with ’s “bring your baby to work” proposal. While of course impossible to generalise to every type of workplace and work schedule, this is a great way to normalise both the presence of babies and children in spaces not ‘meant for them’ (thereby also questioning the legitimacy of such segmentation) and the fact that alloparents can also play a role in caring for children (thereby reducing the expectation that parents have to do it all by themselves). It also helps to make visible the work associated with parenting, potentially raising its value in the eyes of those with no direct experience of it.

Another strategy consists in building porous care institutions from the start. Michel Odent’s concept of ‘home-like birth centres’, for example, is a now increasingly adopted compromise that brings both the benefits of a familial, organic-feeling environment and the safety of an institutional setting. In a similar spirit, there has been a recent re-emergence of intergenerational shared sites that merge childcare and eldercare facilities.

Pioneered in Japan in the 1970s, these facilities come in a variety of forms: a preschool or a daycare inside a nursing home, a residence for older adults next to an afterschool community centre for kids, etc. Kids might simply play in a delimitated area within the nursing home’s garden, or have dedicated shared activity times with elderly residents - reading, creative writing, theater, cooking. The sites have nothing but benefits for everyone involved: the young are more tolerant, more comfortable around disability and difference; they learn skills and hear life stories from their elders, and develop creative pursuits under their coaching. They learn to be around a variety of adults who aren’t family, with a diversity of lived experiences.

The elderly participants, meanwhile, are healthier, less isolated, live longer, and most importantly feel helpful, needed, and valued. The sites encourage prosocial behaviours, sensory stimulation and intellectual development in both age groups. One paper also highlights that “the nurturing presence of older adults helps bring a familial aspect to the preschool setting”, potentially offsetting some of the more anxiety-generating aspects for young kids.

Shared sites are also more attractive to staff, raising the value and meaning of their work while making it logistically easier for them to meet their own family caregiving needs. French startup Tom&Josette, a network of micro-creches implanted within eldercare facilities, built their entire organisational model around valuing the expertise and field experience of daycare workers. On each site, decisions are decentralised, teams are more engaged, and governance is shared and more flexible. On top of their day-to-day responsibilities with the children, the early childhood professionals design the modalities of their interactions with the elderly residents and have their say in the recruitment of incoming daycare staff.

Founders Astrid Parmentier and Pauline Faivre say they were inspired by Dutch at-home healthcare company Buurtzorg, founded in 2006 by Jos de Blok and a team of professional nurses. Frustrated with years of bureaucratic reforms that impoverished their profession and stripped their relationships with patients of their humanity and of opportunities for connection (that lovely institutional care-icide effect again), they set up Buurtzorg “to look after people at home, in a way their values and craft demanded.” [The name translates to ‘neighbourhood/community care’].

The Buurtzorg model has three core principles: a holistic, rather than purely medical, view of the human person and her needs beyond the physiological; an emphasis on the quality of the caregiver-patient relationship, notably by minimising the number of different individuals caring for a single person; and a priority put on the patient’s autonomy, through therapeutic education and the mobilisation of their social support network. Buurtzorg nurses also have a much greater latitude in making decisions around timetables and patients’ needs.

Over the course of a couple years, the company revolutionised in-home care in the Netherlands, rising to the top of patient satisfaction rankings and reducing spending by about 40% per accompanied person, which translated to an average of 3000€ in savings for the patients themselves. They showed that bureaucracy and aggressive management styles were not vital, but actually detrimental to good care organisations. In 2011 and 2012, they were voted the country’s ‘best employer of the year’.

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All hands on deck

Tom&Josette and Buurtzorg are both for-profit companies. They’re also remarkable examples of formalised caregiving that doesn’t completely drain care of its human and relational essence. They show that the spectrum of social change around caregiving is not zero-sum: while we should keep radically rethinking the way we structure care in our societies, there is also hope in building desirable innovations within existing constraints. As put it in her interview with Anu Sharma, founder of perinatal care startup Millie:

“It’s tempting to join the ‘blow up the model and build something better!’ rally cry [...], but the conversation with Anu added a critical angle: how do we ground the rally cry within the constraints of the healthcare system, target the right levers of change, and continue to effectively move the needle forward.”

We can still be critical of institutions, still strive to foster organic spaces and community outside of economic equations. We can also build resilient alternatives that future generations will have the luxury of taking for granted.

The fact that an organisational philosophy originally designed for at-home eldercare can inspire innovations in childcare is also a perfect example of the need for further integration across care systems, as well as between thinkers and practitioners. The Fifth Wave’s mission is to be a space for such integration to happen. A platform where a philosopher specialised in the ethics of care can learn from the hands-on experience of a nursing home worker; where a father eager to do more for parents can connect with a midwife to start a local perinatal support center. A hub for bold, radical and pragmatic thinking about the futures of care.

If that’s something you care about, you’re in the right place. Welcome to The Fifth Wave.