Dear all,
This newsletter is a year old. I published my first piece last July, when I was unsure what this project would even be. Though it is still in many ways evolving, I now know with enhanced clarity that I want my research, writing, thinking – and, hopefully one day, my professional practice as a midwife – to form a coherent interwoven whole around the centrality of care. This newsletter is a piece of that whole.
I am grateful to all who have helped push it along, reading and sharing, as well as those imparting their own wisdom about care on Substack and elsewhere, thereby enriching our collective understanding. I have learned a great deal from you. I am also most grateful to those who chose to value this work through a paid subscription; your support is deeply appreciated.
The Fifth Wave will be taking a break in August. For this month’s (late) letter, I chose to re-visit one of my first articles, refreshing its argument and updating it with new insights to reflect the year’s progression towards a more precise approach to how we organise care. I hope it proves stimulating.
Can institutions care?
In an article, the British charity Hopes and Homes for Children (HHC) asserts that “institutions cannot, by definition, care”.
The term ‘institutions’ refers here to orphanages, “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.1 But abstracting away from the specific context of HHC’s mission, that sentence sums up much of the sentiment around the architecture of caregiving in modern societies.
Care institutions – the organisations and spaces that formally structure the provision of care to children, pregnant women, disabled people, older adults and other groups, and which include nursing homes, foster centres, daycares, hospitals, clinics, and at-home healthcare services – are often synonymous with poor care. Bureaucratisation and siloed systems chop up family and community life, compartmentalising society into artificially neat categories. Many sites where care is delivered are rife with discrimination and abuse, as documented (to take just the example of maternity care) in the UK’s damning recent Ockenden Review and Amos Report, and by Obstetric Violence Observatories across the world.
Strained systems prioritise technical outcomes over meaningful human connection and emotional well-being, which get relegated to mere add-ons instead of central KPIs. Corporatisation and methods like task-based pricing in hospitals incentivise the optimisation of discrete procedures at the expense of the equally vital moments of interaction between patients and staff, leading to worse health outcomes, lower patient satisfaction and higher rates of medical staff burnout.
The various industries in the care sector are plagued by headline after headline showing how privatisation and compartmentalisation produce 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.
For a first-person exploration of what a squeezed care system does to providers, see Rebecca Mack’s essay about her experience as a midwife in the NHS:
“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.”
Careless care
This tension runs into what I’d like to call the ‘institutional paradox of care’.
On the one hand, in order to respond to everybody’s care needs at a society-wide level, care must be scaled and formalised. Though embedded in wider political and cultural phenomena, including appetites for social control, care institutions typically arise out of necessity: the medicalisation of childbirth sought to curb unacceptably high maternal mortality, the creation of daycares to facilitate women’s access to employment, and the advent of nursing homes to provide an alternative to family support in old age amid rising life expectancy and family isolation. Institutions 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 their dependents alive and their communities thriving.
Yet, the characteristics necessary to achieve the provision of care at scale are also precisely the ones most antithetical to good care. There lies the paradox. Facilities being publicly funded helps keep them accessible to a wide range of people regardless of income, but that also makes them vulnerable to austerity measures and neoliberal logics. Privatisation can relieve pressure off state budgets and create a greater variety of options, but also subjects care to potentially deleterious profit-seeking calculations. One-size-fits-all models are easier to roll out nationally, but they risk leaving no space for individual needs and experiences.
Care is, at its core, a relational process – and trying to standardise it into a replicable and minimally costly service acts on relationality like Roundup on a patch of green grass. It is structural care-icide.
It can therefore seem that institutions indeed “cannot, by definition, care”. It feels as though we are faced with a binary choice: either completely disengage from formal structures to preserve the spontaneous and organic nature of care – but as we know, that is only an option for a few, and families are by no means exempt from domination and violence – or ‘give in’ to institutions that inevitably strip it of its relational essence.
But this status quo is not, in fact, inevitable. Formal care structures don’t have to be soulless vessels we are forced into by modernity for lack of viable alternatives. When built correctly, they can also be places of beautiful connection and joy. The way care institutions are designed today, which makes them unfriendly to relationality, has nothing to do with the nature of institutions per se: it is the product of a patriarchal dualism which treats the body as entirely detachable from the mind, and deems emotions, empathy, and embodied experience feminine traits to be given no place in the ‘serious’ public realm. It is a choice, and we can make a different one.
A way forward
How, then, do we overcome the paradox? How do we formalise care in a way that provides much-needed structure to social life and relief to caregivers, without manufacturing disconnection?
As often, the boring, nuanced answer is the most promising one: compromise. Building institutions that leave enough space for the natural porousness of care to freely manifest – ones that institutionalise fluidity. There must be, of course, substantial support, resources and recognition for those who do want to ‘opt out’; 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. Institutionalising fluidity implies also to systematise choice. But formal facilities that preserve the essence of care should be widely available for those who need them.
Michel Odent’s concept of ‘home-like birth centres’ is one such compromise, which brings both the benefits of a familial, organic-feeling environment and the safety of an institutional setting. A similar logic was applied by the Ethiopian Ministry of Health in the early 2010s to design maternal care facilities respectful of cultural customs.
Fluidity is also the driving principle behind the emergence of intergenerational shared sites that merge childcare and eldercare. 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, et cetera. Kids might simply play in a delineated 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, and live longer, feeling helpful and valued. The sites encourage prosocial behaviours, sensory stimulation and intellectual development in both age groups. One paper highlights that “the nurturing presence of older adults helps bring a familial aspect to the preschool setting”, potentially offsetting some of its more anxiety-generating aspects for young kids.
Shared sites are also more attractive to staff, raising the 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 organisational model around valuing the field expertise of daycare workers. On top of their day-to-day responsibilities with the children, early childhood professionals design the modalities of their interactions with the elderly residents and have their say in the recruitment of incoming 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 reforms that impoverished their profession and stripped their relationships with patients of their humanity and of opportunities for connection, they set up Buurtzorg (whose name translates to ‘neighbourhood/community care’) “to look after people at home, in a way [their] values and craft demanded.”
The Buurtzorg model has three core principles: a holistic 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 heavy bureaucracy and aggressive management styles were not vital, but rather detrimental to the economic health of good care organisations. In 2011 and 2012, they were voted the country’s ‘best employer of the year’.
The Buurtzorg model was also chosen by François Génin, who I interviewed back in May, as the organisational ethos for the palliative care nonprofit he co-founded:
“Many people in palliative care suffer from anxiety or sometimes severe depression, and these conditions can lead to up to twice the level of medical care consumption, and significantly increase recourse to emergency services. Because of this interplay, it is essential to build a management culture that allows medical and non-medical skills to work together smoothly.”
The above are all examples of formalised caregiving, both public and private, 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 Molly Dickens, PhD 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 should be critical of flawed institutions, strive to foster organic spaces and community outside of economic equations. We should also build resilient institutional alternatives that future generations will have the luxury of taking for granted.
The fact that an organisational philosophy originally designed for at-home eldercare inspired innovations in childcare is a good 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 hub for bold, radical and pragmatic thinking about the futures of care, centered on the innovative models emerging across the world. Whether you have been here for a year or a day, welcome, there is much to be explored.
– MM
Further reading:
‘What is institutional care?’, Hopes and Homes for Children, 4 July 2019. Accessed 31 July 2026. Commas in the above quote added.
Great essay. I really enjoy your substack and learn a lot from your writing. I think the challenge of scaling care - or support for care - is one of the central issues of care; conceptually and in policy. I've been thinking - wrestling - with this a bit in the concept of care infrastructure: infrastructure that cares, and care as infrastructure. In neither case, do I think the concept really works and while the phrases might have rhetorical or political value, I don't think they actually help us improve and expand care.
I'm not sure, but the same might be true for care institutions or institutions that care. We might be better off reserving care for the very granular and relational experience/service/activity between specific humans. And finding other words and concepts for scaled versions of that.
A relevant problem is that care is highly heterogeneous and also temporally variable (changes over time). So, scaling care to industrial levels will inevitably miss the mark in many (most?) cases.
Anyhow, just thought I'd comment and thank you for your writing and thinking.
Here's a recent blog from me: https://niawag.substack.com/p/infrastructure-as-care?r=9kmoz&utm_campaign=post-expanded-share&utm_medium=web
Thanks for this, Mélina. A lot to follow up on : I knew about the pioneering examples of intergenerational care, which I think are wonderful, but the Buurtzog and other models you write about here were new to me. Some parallels with the very first episode of my Careful Thinking podcast, on relational care: https://carefulthinking.substack.com/p/relational-care-mary-larkin-and-manik