Overcoming the institutional paradox of care
Why formal care structures are so flawed, why we need them anyway, and some inspiring strategies to build better ones
I recently came across the term “institutional care” in this note by Nancy Reddy :
I wasn’t immediately sure what this referred to. Without context, I would’ve thought ‘institutional care’ just meant 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, etc.
But the term clearly had a pejorative association, and upon looking it up, I realised that ‘institutional care’ essentially 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. Just so we’re very clear, this is not what I am talking about in this piece.
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 Elliot Haspel’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.
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 Dylan Macinerney’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’.
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 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 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.
Quote by Jay Chaudhary from the cited article, ‘Beyond False Binaries in Care’.
Thank you for including me in this excellent piece, Melina!