Like many these days, I have been wondering about the (German) care system, about care infrastructures and what it means that across the world, care homes appear to be the place where most COVID related deaths arise. As Owain Williams has outlined in this blog before, moving past this pandemic means understanding that the aged care system in many nations is too fragile to absorb shocks of this magnitude and scale. It means we must ask questions about neoliberalism and privatization, about the relationship between care and capital.
At this stage I wonder whether, while immensely important, considering the role of nursing homes and hospitals as hubs of transmission and as worthy of attention alone may prevent a more nuanced and critical look at the wider system of care infrastructure, about specific vulnerabilities and the role of home care arrangements for wider security concerns.
In the case of Germany’s care infrastructure system, home care arrangements make up the majority of the four million care arrangements. Despite the fact that in the German case, more than two-thirds of people in need of care are cared for in their own home, they seem to be largely absent from public debate. Why is that? I came to think that it may be because we don’t consider home care arrangements to be a matter of public interest, much less of national security considerations (i.e. pandemic preparedness). It does not come naturally to think of close private relations of care as “critical care infrastructure”. And yet, I have a feeling this pandemic won’t be dealt with adequately as long as we overlook specific needs of and ethical aspects related to those being cared for at home, and those doing the caretaking work in such complicated circumstances.
As we have witnessed tragic examples of nursing homes being overwhelmed by the current epidemic, the importance of resilient care infrastructures for the proper working of societies has entered our minds. The question of how to support care homes so they would not become COVID hubs crept into public discourse – and rightly so. It comes as no surprise to those thinking about health governance that the care systems of all nations, especially care homes, are hugely important places to consider anytime, but especially in times of an infectious disease outbreak. However, the backbone to Germany’s care infrastructure is arguably its decentralized network of home care arrangements – a form of social organization which is much different than hospitalized care or nursing home arrangements. By overlooking this networks’ importance for upholding the German care system’s functioning, we are not only overlooking important aspects to health security considerations in pandemics, but also prevent turning to difficult ethical questions about justice and individual and societal responsibilities to care in times of crisis.
During this pandemic, the support networks for people in home care often break away because physical distancing measures are difficult to uphold or because friends may be at risk themselves, meaning that (predominantly female) family members have to face the struggle of caring, working and replacing professional nursing jobs all at once, with the added bonus of pandemic fear and uncertainty. Particularly households in the lowest income groups are forced to resort to home care over other care facilities, meaning even at the best of times, questions of equality and responsibility arise regarding the types of arrangements that build the infrastructure to our societies’ functioning, particularly in times of crisis.
What makes home care particularly noteworthy in this virus pandemic is therefore that on top of questions about gender and class inequalities, considering the hugely diverse home care infrastructure system brings new questions to the table: How can family members think about going back to work, when this could increase the risk of infection for those people we are taking care of? When the social life and medical support network of people being cared for at home crumbles due to COVID restrictions, when governments cannot provide for job safety and professional support networks for all those caring for loved ones at home, does this mean that a large part to critical care infrastructure protection rests on the kindness and patience of family and friends? How can thousands of people receive adequate care when their social and medical needs are not met because we don’t consider their requirements to be different to those in care homes and hospitals?
Debating the role of care homes and hospital infrastructures can only be part of the solution to moving past this pandemic, because it covers only one third of those people (in Germany) who are being cared for at home or who do the caretaking work under the pressure of a pandemic. In addition, we can ask which kinds of vulnerabilities we are considering these days and which needs we might overlook. These questions are fundamentally ethical, but I think that in relation to security considerations and adequate containment, they become questions of security ethics. It means that, besides asking questions about the relationship between capital and care, wondering how best to prepare nursing homes for a pandemic disease outbreak through medical technology, it is important to ask questions about the relationship between inequality and care infrastructures, about who we consider to be most affected and about difficult responsibilities, which arise in home care arrangements.
We must not forget that in many places, even the access to care homes is a privilege, meaning that when the majority of the debate focuses on hospitals and care homes alone, we may take a step in the right direction, but still overlook those people who are part of the care system, just on a different level. To begin with, these dynamics cannot be solved by financial means alone, but they heavily rely on whether we view certain relationships and infrastructures as important to consider in public health and health security strategies in the first place.