Abstract
What is the value of care? This paper examines economic repertoires used to measure and evaluate care and by extension, the value of human life, social relations, and labour. Drawing on our respective ethnographic research on health insurance in Brazil and elder care in Ghana and the United States, we analyse economic repertoires of zero-sum thinking, sacrifice and obligations, and rights-in-people, all of which posit that there is a commensurability between the economic and the social, as well as discourses which make them incommensurable. This list is suggestive rather than exhaustive. Through these examples, we delineate a path forward beyond frameworks of hostile worlds, in which care and the economy (or capitalism or neoliberalism) are pitted against one another. We argue that putting capitalism at the centre of the analysis of care has obscured the ways people manage care and its associated conflicts, although we understand that capitalism provides a larger context in which people navigate decisions and actions. Instead, in this paper, we focus on how care generates dilemmas which force people to measure its value. The economic repertoires that they use to manage these dilemmas differ from those associated with capitalism, supporting theoretical work on the ways that capitalism, as an economic system, is hybrid and infused with non-capitalist repertoires and practices.
What is care worth? One approach, developed by economists, is to assign a monetary value to unpaid care labour. A recent report based on US consumption data (Zacharias et al., 2024) sparked a debate among feminist economists about the best ways to measure unpaid care labour, particularly in contexts where the informal economy is more prominent than in the United States. In seeking a monetary value to unpaid care, feminist economists aim to reconfigure the value of care in the dominant rhetoric of value – money – although anthropologists would prefer broader and multiple ways of determining worth. Other perspectives on the relationship between care and money are similarly limited: social ways of organizing finances are generally seen as posing a limitation to care or even as antithetical to the work of care. 1 For example, neoliberal economic policy or global capitalism is often used to explain constraints on care systems in social welfare states (Bourdieu, 1998; Han, 2012; Muehlebach, 2012; Tronto, 2015). In the absence of state care, gendered and aged access to financial resources may determine access to care on an individual level, and thus affect the quality of life and life expectancy (Cliggett, 2005). In this paper, we would like to unpack the economics of care without treating ‘the economy’ as a black box or a universal force, and without separating economics from social relations. Building on the work of others, we aim to contribute a more robust conceptual language for understanding the economic exchanges that support and destabilize the labour of care, based on our ethnographic research. We use the concept of economic repertoires to examine how care is embedded in economic relations. Global capitalism and neoliberalism need to be part of the analysis of care, but in order to understand how they affect care, they should be considered in light of the constraints and inequalities that exist within a constellation of exchanges. Such an approach acknowledges that care dilemmas relate to capitalism while simultaneously questioning the centrality of capitalism and neoliberalism to the analysis.
As we discuss further below, care is considered by some thinkers to be an unalloyed good, promoting the wellbeing of individuals and communities. For example, Berenice Fisher and Joan Tronto (1990) developed an ethics of care which reflects this positive valence: ‘in the most general sense, care is a species activity that includes everything we do to maintain, continue, and repair our world so that we may live in it as well as possible. That world includes our bodies, our selves, and our environment, all of which we seek to interweave in a complex, life-sustaining web’ (Fisher and Tronto, 1990: 40). Other studies, particularly from the lens of disability studies and medical anthropology, have illustrated the shadow side of care, highlighting its dangers to autonomy and personhood (Mattingly, 2014; Van der Geest and Platenkamp, 2023). For these reasons, rather than Fisher and Tronto's definition, we prefer Virginia Held's (2005: 35) more open-ended definition of care as ‘a relation in which carer and cared-for share an interest in their mutual well-being’. We take an agnostic view on whether care is positive or negative; instead, we consider care to pose a set of dilemmas which prod those providing and receiving care to assess its value and rationale. 2
One way that this dilemma is visible is that definitions of ‘good care’ are contested, such that care is always falling short in one way or another. For example, the quality of care is hard to measure: good care according to state regulations may mean meeting certain bureaucratic regulations, like caregivers receiving a certain kind of training or certain boxes being ticked in medical paperwork (Showers, 2023). For some, good care might mean preserving the dignity or autonomy of persons, whereas for others, it might mean preventing physical death or decline. The limitations of care are particularly revealed in death, which comes to all humans, whatever the quality of the care they receive prior or after that point (Bähre, 2007; 2020a; Chan, 2012; Golomski, 2018). Care can increase the quality and length of life, but can never preempt death. The limitations of care confront us with the fact that life itself is finite. For these reasons, care can always be criticized as limited and inadequate.
Secondly, care requires social and material resources, sometimes to a significant extent. Caregivers can sacrifice themselves for the wellbeing of others. Similarly, those receiving care can accept neglect in order to foreclose being a burden on the caregiver. Different kinds of care, like pharmaceuticals, may be substituted for more difficult relational care and the labour of individuals (Biehl, 2012). The kind of labour and the weight of resources entailed in care can lead people to evaluate the worth of care, including in relation to the care needs of other people. Today, decisions about care are often also decisions about money. Care decisions are then also decisions about the ‘pricing’ of health and other questions concerning the commensurability of moral and economic value; about how care is made up of market exchanges as well as other forms of exchange associated with gifts, reciprocity, and redistribution; and also about how exchanges represent self-interest and the interests of others.
Finally, care creates dilemmas by transforming relations, as people shift position in relation to one another to provide and receive care. People can become closer to one another through care, by sharing vulnerabilities and knowing one another; paid care workers may be kinned temporarily and provisionally (Amrith and Coe, 2022; Read and Thelen, 2007). Tensions can also arise as a result of care, between caregivers and care recipients and between multiple potential care providers over their roles, over what good care means, or who should do what. Thus, in care, people are deeply engaged in assessing their relations to multiple others, which are in flux as a result of those same care practices. These transforming relations then also transform notions of the self (Kusimba, 2021). Personhood is, after all, relational and when care transforms relations, it also transforms how those who are involved in care perceive themselves and others.
In this paper, we want to provide a conceptual language for thinking about the value of the exchanges that make care possible, as well as limit it. These assessments are constantly being made in care relations because of the dilemmas that arise within and around them. In our discussion, we look at different domains that are often treated as separate: insurance policies, institutional care, paid care, and unpaid care by kin. Analytically, our approach makes sense because these domains are not distinct in everyday life: people are managing different forms of economic and social exchanges simultaneously and weighing different care arrangements against one another. Rather than focusing on specific domains like paid versus unpaid care, because of the messiness of separating them (Amrith and Coe, 2022; Coe, 2024), we argue that scholars should analyse the economic repertoires that are utilized across these domains. We make this case using examples from our respective ethnographic fieldwork: Erik Bähre on the care dilemmas posed by healthcare and health insurance markets in Brazil, and Cati Coe on the paid and unpaid care of older adults in the United States and Ghana.
By repertoires, we mean discourses and embodied practices that are socially learned (Coe, 2013). Repertoires generate moral evaluations of behaviour and action. The repertoires we focus on are economic in that they involve obligations or exchanges of finances, labour, or other economic resources like property. These economic repertoires provide interpretive languages and moral lenses for people to reflect on and navigate the care dilemmas they encounter. As with other ways of assessing worth (Boltanski and Thévenot, 1999), people mix and match these repertoires to evaluate the care dilemmas they face. They provide people a way to make sense of their lives, evaluate the moral implications, and motivate certain actions (Berger and Luckmann, 1967/2011/2011; Boltanski and Thévenot, 1999; Tavory and Eliasoph, 2013; Zilberstein et al., 2023). These repertoires offer insight into agency while accounting for the way in which people are embedded in social and institutional networks and rely on cultural and symbolic understandings of the world (Lamont and Thévenot, 2000; Swidler, 1986). It is through these repertoires that we have access to ‘the multiplicity of power and the potentially liberating and transformative aspects of intimate subjectivities,’ that would otherwise be flattened if we focus on the pervasive power of capitalism or neoliberalism (Constable, 2009: 60). Although economic repertoires have been analysed implicitly in economic anthropology, particularly through the work of Jane Guyer (2004) and Parker Shipton (1995), the term itself has not been regularly used. We propose that these repertoires are useful for anthropological understandings of the economics of care, because they give us a way of analysing care dilemmas beyond the hostile worlds posited between love and money. Although the hostile world thesis has been critiqued over the past 20 years (Constable, 2009; Zelizer, 2005), it has been hard to move beyond. Focusing on economic repertoires, we believe, provides scholars with a positive analytic direction.
We prefer to use the term ‘economic repertoires’ – and not the more familiar term ‘cultural repertoires’ – to highlight that economies are constructed and that interlocutors can draw on multiple and naturalized perspectives on the economy. The term ‘economic repertoires’ emphasizes simultaneously that the economy is constructed within specific social, political and historical configurations and that decisions about the economy are seen as self-evident and natural. People deal with care dilemmas through combining and overlapping diverse economic repertoires to manage and reflect on the value of care; in our research, we observed repertoires of zero-sum thinking, sacrifice and obligations, and rights-in-people. These economic repertoires rely on different temporal horizons. Like the feminist economists noted above, these repertoires treat economics and care as commensurable. However, we also observed a repertoire that refused commensurability between economics and care as a way of navigating care dilemmas. In the sections that follow, we first discuss the dominant theoretical ways of discussing care and the economy, before turning to the repertoires we saw enacted in our respective fieldsites.
Key approaches to care in relation to the economy
Care has become prominent in anthropology and other fields over the past decade. The attention to care is primarily due to the work of feminist political scientists, economists, and sociologists, who drew attention to the importance of care more broadly within the social sciences. In their formulations, care is often contrasted with markets and global capitalism, because care work is devalued according to market forms of value, whether unpaid in households or poorly paid when deployed as paid care services. Joan Tronto, an influential theorist on the ethics of care, points to how economic forces and economic ideologies create a growing ‘caring deficit’. According to Joan Tronto (2015), the ‘caring deficit’ that people are facing today is the result of a political ideology that supports market thinking to the detriment of care. She argues that the mechanisms and ideologies of the market undermine care as these ideologies are the opposite of the morality on which care practices are based. Care practices, unlike markets, are based on practices that are ‘always relational’ and recognize people as relational selves, rather than individuals. To solve the deficit in care, she argues, we therefore need a political ideology that pushes back against destructive market forces and neoliberal ideologies: ‘We need to stop trusting that “the market” will somehow magically meet all caring needs …. We need to demand that caring responsibilities be reallocated in a way that is consistent with our other values, such as equality, justice, and freedom’ (Tronto, 2015: 37–38). In political philosophy, care is considered to have the radical potential to create new normative ethical frameworks around a care economy or caring society based on human vulnerability and solidarity (Hamington, 2015).
Similarly, feminist political scientists have argued that capitalism makes it difficult for families to reproduce themselves, drawing on the Marxist idea that capitalist accumulation relies on the devaluing of social reproductive and care labour (Federici, 2012; Fraser, 2016; see also Kalb, 1998). Feminist anthropologists have argued that the ideological and material foundations of capitalism mean that care, as social and biological reproduction, is systematically undervalued (Glenn, 2010). Thus, one can make visible the cruelties and contradictions of capitalism through a lens on care: in the words of Arlie Russell Hochschild, ‘Increasingly we feel in our moments of detachment and neglect the referred pain of unfettered global capitalism itself’ (2003: 3). As a result, over the past 20 years, the notion that capitalism is exploitative of caring relations has become hegemonic within the feminist literature on care and social reproduction. These perspectives have also influenced medical anthropology. Annemarie Mol (2008) contrasts the logic of care to the logic of choice, which she attributes to market mechanisms. While the logic of choice posits the patient to be an autonomous agent, an individual, the logic of care is oriented to practically improving the situation for patients through its embodied practices. These logics set up radically different dynamics that have implications for other aspects of social life and political organization. In his commentary on Mol, Biehl (2012) argues that market capitalism creates the possibilities by which the logics of care and of choice are opposed to one another in a dichotomous fashion.
Hochschild, Tronto, and Mol importantly contribute to our understanding of how ideologies regarding the market affect the moralities and practices that enable care. They question the gendered inequalities that global capitalism produces and recognize that care arrangements have a longstanding history of unequal racial, gender and class relations. In their view, the caring deficit can be solved by challenging uncaring markets and capitalism, both from an ideological and institutional point of view. The key to solving the caring deficit is by valuing caring social relations or creating a care economy, an economy based on providing care rather than based on markets that provide choices to consumers. This widely adopted approach shares similar beliefs to modernization theory, in which changes in the economy are seen as driving changes in care practices. Modernization theory posited that as societies progressed from ‘traditional’ to ‘modern’ through economic development and became more integrated into global capital flows, care relations would radically change (Stephens, 2015). In particular, the family would become less important to care, replaced by markets: family networks would shrink, the birth rate would fall, and people would seek commercial care services instead.
This approach of contrasting care logics to the market also builds from a critique of neoliberalism as one of the most fundamental and damaging change in governance that has occurred in the past 40 years. Studies show how neoliberalism promotes the market and market thinking; aggravates inequalities; increases violence; transforms religious imaginaries; and introduces new subjectivities that undermine human rights and generate anxiety (Comaroff and Comaroff, 2001; Elyachar, 2002; Isin, 2004; Lavinas, 2017; Molyneux, 2002). Neoliberalism puts greater pressure and responsibility on families and communities to provide care. Nguyen et al. (2017) argue that neoliberal ideologies promote a new prudentialism that makes the individual ánd the family responsible for care. They point to a contradictory process where ‘the moral logics of care drive people to engage in actions that are both productive for building communal and ethical lives and reproducing the very ideal of the self-interested individual that eventually undermine the solidary linkages that gels society together’ (Nguyen et al., 2017: 210). Andrea Muehlebach (2012) similarly argues that the retreat of the state in Italy has enabled a new emphasis on voluntary work by private citizens. Catherine Alexander (2009: 239) argues that the UK state is undergoing a transformation from a welfare state to a penal state by ‘externalizing functions of care (and the risk of their operation) to the third sector’.
Marketization and neoliberalism are now centre-stage in an academic discourse that implies they displaced a once harmonious and caring world (Bähre, 2015; Maurer, 2006). However, neoliberalism is not always a helpful analytical category (Eriksen et al., 2015; Ferguson, 2015; Ganti, 2014). The problem is that it risks universalizing experiences and attributing the malignant practices of people and communities to abstract economic forces, such as numbers, calculations, financial institutions, indexes, or other classification systems that are disseminated by marketization (Biehl, 2012). If abstract markets are seen as the fundamental problem that preclude or prevent caring relations, this results in the argument that we should strive for a social, personal, and embedded economy. This approach to the economy risks reifying the idea that human relations could be harmonious and dignified if they were not ‘contaminated’ by abstract, impersonal economic forces. It suggests that human dignity can be regained by carving out a niche that is separate from global markets; for example, by creating social networks based on caring, cooperation, or gift exchanges. This view resonates with what Viviana Zelizer (2005) defined as the ‘hostile-worlds view’, which wrongly assumes that the world of markets and the world of social intimacy are intrinsically hostile toward each other, rather than deeply intertwined (see also Bloch and Parry, 1989). However, as Keith Hart et al. (2010) also argued, this dichotomy should not govern our analysis.
Our aim is to find a conceptual language that is both more nuanced and more systematized than these key approaches in helping us understand how people pragmatically navigate care dilemmas. We posit that although people identify these dilemmas differently, we note some similar tensions across our research sites in Brazil, Ghana, and the United States. In the sections below, we outline different economic repertoires that assist people in understanding, interpreting, and managing care dilemmas: zero-sum thinking about the collective good, sacrifice and obligation, and rights-in-people, and the shifting incommensurability between the economy and care. There are, no doubt, other economic repertoires available for reflecting on care dilemmas; we provide this list as an invitation for others to be generated, not as a comprehensive list or universal template. We focus on these particular dilemmas because they were key to the very diverse circumstances that we encountered during our respective fieldwork. But we also focus on these particular dilemmas because we think that they require more empirical attention and conceptual development when analysing the nexus of care and the economy.
With this starting point, we identify how economic repertoires, in various forms, inform, contest and help people manage care dilemmas. The dilemmas, we suggest, are always present, but people make sense of them through various economic repertoires, in deciding which actions to take in the situations they face and in providing moral evaluations of these actions.
Zero-sum thinking or care as a limited good
One economic repertoire is to consider care as a limited good, in which one makes tradeoffs between one person's benefit and another's. Leo Hopkinson's (2023: 226) analysis of boxing in Ghana is helpful in revealing the situatedness of zero-sum thinking. He points out that boxing might be considered ‘a zero-sum game—for every winner there must be a loser’. At the same time, his own research shows that boxing is not always a zero-sum game, because it depends on a pool of good, but not great, boxers against whom the rising stars can play and practice. These regular match partners must remain healthy, so the stars should not hit them too hard. Temporality (in the sense of imagined futures) and relationality matter a great deal in whether a particular match is seen as a zero-sum game or not.
The situatedness of the zero-sum way of thinking was particularly prominent in Erik's work on healthcare and insurance in São Paulo. A doctor working in a private hospital argued that people want to buy a Volkswagen Beetle yet drive a Mercedes. Laughing, he explained that this is simply not possible and that if you want better healthcare you inevitably need to pay more money. Throughout the conversation in his consultation room, he presented a utilitarian perspective on healthcare where people want the best healthcare for the lowest price. A couple of months later, Erik shared this perspective with friends and colleagues at the university. They felt that what the doctor said was highly problematic: ‘How can you turn healthcare into a commodity and compare health and a luxury car?’ someone asked rhetorically. Someone else pointed out that health is a fundamental human right that is guaranteed by the Brazilian 1988 constitution. The critique was that the doctor's approach to healthcare did not consider that healthcare provision is a political decision in which funding is allocated through budgets. It was also criticized for reducing health to a consumer item, even a luxury, rather than treating it as a political right.
These diverging perspectives on health as a limited good were also present in court cases and other conflicts around private health insurance benefits. When Brazilians purchase private health insurance, the political right to healthcare is, as it were, taken over by the private sector. Court cases against insurance companies mostly included moral damage claims that were almost always granted (Bähre, 2023). Judges determined that the moral damage payment compensated clients for the suffering that the company had caused by not granting the political right to healthcare. Judges also viewed moral damage payments as a pedagogical tool to teach insurance companies to improve their behaviour. Judges applied an economically rational argument in punishing the insurance companies for their previous behaviour by reducing their profits.
Conversations with actuaries and other experts who devised the policies for insurance companies presented, in contrast, a different type of zero-sum thinking on the economics of health insurance. They did not view the moral damage payments as an incentive to improve insurance benefits. Instead, they saw them as an additional expense that would make health insurance less affordable. Legal expenses, including moral damage payments, were simply added to other costs and led to increases in premiums overall. Without using the automobile metaphor, several actuaries working for insurers made it clear to Erik that better healthcare would be more expensive and that legal costs would only make it more difficult to make health insurance affordable. The zero-sum perspective of actuaries focused on the tradeoffs between premiums and healthcare coverage. This was a very different perspective from seeing a zero-sum tradeoff between care for the patient and the company's profit margins.
In Ghana, within the context of elder care by kin, care becomes limited not through actuarial technologies, but through formulations of what people need. Food is the sine qua non of good care, which is evaluated through discussions about its quality. For example, the nurse and nurse's assistant running the aged program at a Presbyterian Church in the town of Akropong in the Eastern Region said they had met some older adults who did not receive good care, by which they meant that they were eating porridge without bread, or kenkey (fermented corn which was then boiled) with hot pepper but no fish. Abandoned and neglected older people were viewed as eating low-quality food, such as plain cooked rice, without stew or gravy.
The emphasis on non-nutritious food is a way to define care responsibilities. No older person Cati met was denied food outright, but they were ‘neglected’ in other ways. The nurses of the aged program were concerned about the care of a woman who was given food by her family, but her medical needs were attended to only haphazardly, when her son living in Accra visited and took her to the hospital. Such visits did not result in relief of the pain and swelling of her legs, which made her unable to walk. Her situation helped Cati understand why medical needs were not the focus of care: there were high costs of transportation to the hospital as well as of medical care, and yet after considerable effort and expense, the hospital visit might not be effective at providing relief or cure.
Despite being a way to limit care to the essentials, food was a symbol of good care and attention in general, and as such, it was a way to index other forms of care, like cleanliness and medical attention. In this sense, it was a flexible form of limitation on care, in which people could complain about care through food, rather than limiting care to just food. However, those giving food to an older adult could point to the provision of food to signal that they were, in fact, providing good care in all ways.
Zero-sum thinking was present in weighing the needs of older adults against those of the generation of their grandchildren. An older man told Cati that his children preferred to support their own children, to his detriment: ‘My children have given birth to their own children and traveled to other places. It is hard for them to take money from their own children and send it to me, unless I force it a little so that I can get food to eat.’ In this view, his children have the right to limit their care to their own children, but not if it denies him the right to eat. Through highlighting their hunger, older adults can ‘force’ their children to contribute to their wellbeing, against other potential ways of spending their money on other loved ones. Thus, in kin care, limitations can be placed on care, with the wellbeing of grandchildren pitted against that of older adults. However, there is flexibility within this system because of the ways that food can be used polyvalently – as both a limitation on care as well as metonymically to signal good care in general.
The zero-sum approach to care thus came up regularly in conversations and in various forms during our respective fieldwork. It is an economic repertoire that plays an important role in the organization of care and deciding which resources to use for care. Our fieldwork shows how the limitation of resources for care is socially situated. Care-related decisions or the economics of care are not dictated by one universal notion of zero-sum or limited goods. Instead, people draw on multiple economic models and competing principles. For an anthropological perspective on the economics of care, it is helpful to recognize that the zero-sum idea is invoked in certain moments and that it highlights specific dilemmas that are inherent in the use and allocation of resources. We consider economies to be politically, socially, and historically constructed and dilemmas about resources needed for care to be contingent. When people involved in care refer to care as a limited good, they do not necessarily adopt the universalizing and context-free idea of a zero-sum game that is common in orthodox economics. Instead, the notion is contextual – it is an economic repertoire – as it depends on how a zero-sum situation is identified, constructed, and expressed. Analysed in this way, zero-sum notions have a lot more commonalities with the construction of care as sacrifice, which we discuss in the next section.
Sacrifice and obligation
Sacrifice might be understood as the opposite of zero-sum thinking. Sacrifice places moral reflection at the centre and emphasises that not everything is commensurable to economic value (Lambek, 2008). Individual sacrifice can be justified by emphasizing the value of the collective, which can be a group but also something abstract such as building a national economy (Ozawa-de Silva, 2021). Sacrifice is of particular interest because it challenges utilitarian principles as well as reciprocal expectations of economic practices. In relation to care, sacrifice means putting another's wellbeing before, and at the expense of, one's own. Care as sacrifice is particularly highlighted by female caregivers who feel forced into caregiving roles by others. Whether care is seen as a sacrifice or as an obligation is situational, depending if one takes the perspective of the care-provider or receiver.
In Ghana, the eldest daughter feels a special obligation to return to her hometown from an urban migration to look after her elderly relatives as well as children in the extended family whose parents need help with childcare because of their own migration (what Leinaweaver [2010] in the context of Peru calls ‘the care slot’). The daughter returning home may also have to live apart from her own husband and children (see also Van der Geest, 2002), and if her husband does not agree to her going away, then her return home may also mean the end of her marriage. Returning to the hometown to live with her mother or another elderly person generally means a loss of economic opportunities for the caregiver, although she receives free housing and may be able to farm or trade a little bit on the side in her hometown. Some women are pleased to return to the hometown, where they have access to land to grow food crops and free housing in a family house. Filling the care slot may accord with a stage in the life course where they lose income-generating opportunities in late middle age or wish to separate from their husband after child-bearing. If the eldest daughter cannot return, because of her employment or marriage, then one of her sisters or daughters may take her place. Or a more distant relative may be asked. Because of her sacrifices, a caregiver who returns home expects to be supported by her siblings (particularly her brothers) and grown children living elsewhere. They are expected to visit the family home occasionally, bringing money and gifts when they do so.
Not all women are content to come home to take care of their elderly parents. Sacrifice is particularly highlighted when brothers or children have not reciprocated her care. For example, a 43-year-old woman, Yaa Ofosua, had travelled as a young woman: she had first apprenticed as a seamstress in a commercial town, where she married and worked as a trader. Later, her husband died, and she became involved with another man in a relationship that was much more short-lived. After that relationship ended, she returned home to take care of her mother, whom she described as having difficulty moving around and thus unable to prepare food or fetch water for herself. Yaa was not happy about returning home to care for her mother, because it was much more difficult to make a living in Akropong. She struggled to support herself, her mother, and her 7-year-old child from a family plot in town. She scrimped and saved to pay her son's school fees. She begged her son's father for help, but he was resistant to doing so. She made clothing alterations occasionally and also received firewood and other foodstuffs from helping other farmers. Her mother ran a little bar out of the house and her brother sent money once in a while, but not enough to satisfy her. Yaa wanted one of her ten siblings to take her place in looking after her mother, so that she could migrate again. In the presence of her mother, she stated: I would like to tell my siblings that I am exhausted of looking after my mother; I would like to go look for work in Suhum or Tema or Kumasi [all commercial towns or cities] and if I could find someone who could take me on or if I found work, I could bring money back to my mother, and she could look after my child or something like that. Or if I go with my child, I could bring something to my mother. And that would mean that my siblings would come; they are many.
In Erik's research, caregiving and sacrifice were similarly gendered. Through the influence of Catholicism, sacrifice was a more important ideology in Brazil than in Ghana, in which the rewards were not solely in the here and now, but also in the afterlife, and were primarily moral, rather than based on financial exchanges from kin. For some caregivers, the Virgin Mary was an icon of sacrifice, providing an unattainable model. Bruna was in her forties and lived with her parents in one of the poorer parts of Brasília. Bruna never married, had no children, and continued to live with her parents. She told Erik she never planned to have a family of her own. Bruna was the youngest child, and, according to some, it is tradition for the youngest daughter to be responsible for taking care of parents. Erik talked to Bruna in the living room of her parents’ house, where Bruna's parents were always around. Therefore, it was not possible to talk with her privately. The walls of the living room, decorated with images and statues of the Blessed Virgin Mary, provided a template for Bruna's life. Unlike Mary, Bruna's sacrifice was not for her son but for her parents. Women, especially daughters, were pivotal to healthcare arrangements. At the same time, not all daughters were prepared to make this sacrifice. One woman explained to Erik that she left the relatively prosperous life she had on her parents’ farm in order to work as a domestic worker in Brasília. The reason for this radical choice, which was at the expense of her status and comfortable economic position, was that she did not want to sacrifice her life by taking care of her parents. When he interviewed her, she was already in her 90s, and although her life in Brasília was far from easy, she did not regret having left.
Sacrifice is reminiscent of zero-sum thinking in that it highlights that the interests of people do not always converge. At the same time, sacrifice, as part of an economic repertoire, also challenges reciprocal expectations as the sacrifice means that there is no return exchange, at least not in this life. The examples from Brazil and Ghana highlight that sacrifice is a powerful repertoire in which moral evaluation is integral to economic values when measuring who deserves care and who is expected to provide care. But there is another repertoire which draws on a morality that amplifies the inequalities on which care is based without perceiving it as a zero-sum. That repertoire is rights to care, an economic repertoire that we will unpack in the next section.
Wealth-in-people, rights to care
Wealth-in-people is a concept that emerged from anthropology in Africa, describing an economic and social logic in which ‘rights-in-people’ are the main basis of prestige, power, and access to resources. At the basis of wealth-in-people theory is a theory of value in which people seek to hold rights to other people—to their labor, support, reproductive capacity, or property’ (Kusimba, 2020: 167). 3 Rights-in-people can be established through kinship or belonging in other kinds of social groups, including political communities. As Sibel Kusimba (2020: 168) details in a recent review of the literature, establishing rights-in-people is a ‘creative process of cultivating new and diverse embodied qualities and positive attributes in individuals’. Rights-in-people can therefore be contested. Rights-in-people can pertain to forms of reciprocity within kinship but, as we will show, also in labour within the market that creates kin-like expectations.
Rights to care depend on reciprocities and obligations that have been incurred previously or are expected in the future, which Parker Shipton terms entrustments: ‘Entrustment implies an obligation, but not necessarily an obligation to repay like with like, as a loan might imply. Whether an entrustment or transfer is returnable in kind or in radically different form—be it economic, political, symbolic, or some mixture of these—is a matter of cultural context and strategy’ (Shipton, 2007: 11). We are careful not to emphasise the old market-gift duality that has been questioned since the late 1980s (Bloch and Parry, 1989). We agree with Bloch and Parry that it makes more sense to focus on whole transactional systems. At the same time, the distinction that they make in short-term and long-term systems of exchange pits self-interest against social reproduction and morality. Studying complete transactional systems complicates the comparative question that helps to explain the diverse ways in which economics and care are related. So instead of analysing gift versus market, care versus capitalism, we propose a vocabulary that situates both long-term and short-term transactions within a framework of rights-in-people.
Social norms in Ghana deem that parents have a right to care from their adult children because of the care parents provided to support their children's biological and social personhood earlier in the life course. This was often articulated in a Twi proverb, told to Cati by an older man in this way: If your mother or father or someone looks after you while your teeth are coming in, when it comes to the time where his or her teeth are falling out, you look after him or her.
Through rights-in-people established through co-belonging through kinship, people also establish rights to inherit property acquired by kin members. Inheritance is one of the great causes of inequality in capitalist societies (Piketty, 2014). As inheritance takes place mostly among kin, it also reveals how mutuality and relationality can co-exist with capitalism (Gudeman, 2015). Rights to property influence rights to care in complex ways. Property in Ghana has become more valuable, while in Brazil its worth has become less certain. Caregivers and care recipients can weigh the value of property and inheritance differently, affecting their relationships, as is the case with Reynaldo, whom Erik met as part of his research.
Several years before, Reynaldo had bought an apartment. With the financial assistance of his parents, he could afford one in a wealthier and safer part of Brasília with easy access to his workplace and a good school for his daughter. His parents also helped Reynaldo's siblings with their housing. The parents had accumulated many properties over the years, which they expected their children to take over. Yet the houses that his parents owned were in a bad state, despite what they were spending on maintenance. Reynaldo's father did not want to rent out the properties as he wanted his children to use them. However, the children were reluctant to do so because they were not in attractive areas. For instance, Reynaldo's father urged his children to use a beach house. Reynaldo said to Erik: ‘The house is at a shitty beach and it is not safe there, but my father was offended that I did not use their house and instead booked a hotel.’ Reynaldo regularly talked with his father about the properties that the family had, and he was ambivalent about these conversations and the expectation that he would inherit the properties.
When Reynaldo's mother was diagnosed with cancer, she expected her children to help care for her. Her treatment included a long stay in a hospital in Brasilia, during which her children took shifts so that the mother would never be alone. She told her children several times that she took care of her mother and made it clear that she expected her children to do the same. The inheritance of the houses was not talked about directly in this context, but it did make Reynaldo feel guilty. He felt that he and his siblings were forced into a debt relationship because of the houses they had already received, as well as the anticipated inheritance that Reynaldo did not really want. According to Reynaldo, his father did not see that investing in housing was an excellent strategy in the past, when Brazil was burdened with very high inflation, but had ceased to make sense financially. Keeping the old houses was now about maintaining a specific idea about personhood and also about indebting the children, Reynaldo felt. Reynaldo and his sisters did take care of their mother, but he felt that he could not meet his parents’ expectation. These ‘understood’ exchanges for care have been noted in other contexts, in which balanced exchange blurs into market exchange, particularly when property is involved. For example, the historian Hendrik Hartog (2012) notes adults with property in the United States in the 18th and 19th centuries secured care from an adult child through the promise that ‘someday all of this will be yours’ through inheritance. He analyses legal cases in which such informal arrangements fell through, because the older adults did not make a will to that effect, concerned that they would be caught in a King Lear-like situation, where they had no leverage over the next generation's care labour. Sometimes, they made such arrangements with non-kin adults, which kin then contested post-mortem. Although one might expect inheritance to facilitate care from potential inheritors, the situation is more complicated, as Reynaldo's situation has already illustrated. Relying on long-term exchanges is tricky, and the valuations of what is being exchanged can shift and differ between individuals.
Payments to hired caregivers might seem to be different altogether from the long-term exchanges between parents and children and other kin that is associated with a wealth-in-people repertoire. Yet care from paid care workers is often framed in ways similar to the rights to care between kin, as based on mutuality and love, particularly when parents consider their children to have failed them in terms of care (see also Case and Menendez, 2007). As a result, African immigrant care workers in the United States expected an inheritance from their wealthy patients. When the patient dies, care workers often receive something, whether cash, used household goods, or even cars or houses. This is a token, a gift acknowledging the emotional depth of relationship with the paid care worker, but not a true inheritance equivalent to what adult children receive. Furthermore, care workers do not have any right to these gifts; adult children may contest them. This gift tides care workers over for the weeks or months before they receive another permanent case from the agency and supplements their generally low wages, which requires them to work long hours and many cases in a week to make ends meet.
For example, Mariam took care of a former psychiatrist who was emotionally and financially generous. ‘He was rich,’ she explained to Cati, noting that he had a two-bedroom apartment in the independent living facility, rather than the cheaper one-bedroom option. During his lifetime, he had paid for her groceries when they shopped together. ‘He loved me. He said I was like no one in the family, because I cared for him.’ On his birthday, he would give her $5000. With a son who was a (wealthy) doctor and a daughter who was a (middle-class) teacher, her former patient told Mariam that if his son-in-law was rich, Mariam would be rich, but as it was, his daughter and grandchildren needed to inherit his fortune. He wanted to buy Mariam a house, for which she would pay him back, without interest. ‘But it never happened because the children didn’t like it. He left me money, but I never got it. I know how much he loved me.’ She knew he left her money because after the funeral, the son told her that after the lawyer talked to the daughter, she would call Mariam. But the daughter never called. One day, as they were packing away the patient's belongings, the daughter asked Mariam, ‘What shall I do?’ Mariam said she would think about it, and she made up a figure. ‘I came up with: “I have worked for him for three years, so please give me three months’ pay.” That seemed reasonable. She gave me $3500.’ Mariam switched to a logic of employment and severance pay with the daughter with a different temporal horizon. She did not feel that this gift equalled what her former patient willed to her, because of his previous generosity, but it was all that she felt she could legitimately claim from the adult children. Unlike their father, the children did not feel the paid caregiver had the same rights on the basis of her care.
Reciprocal exchanges, and sometimes also market exchanges, establish rights to care from significant others. Yet, like the other economic repertoires, the economic register of rights-in-people can be invoked in many different ways to define the obligations of care receivers and care givers. Care workers can be constructed as temporary kin who can be discarded after the death of a patient or at the end of the care work (Amrith and Coe, 2022). The flexibility of these repertoires is crucial to the exploitation and dominance in paid care work, and they are similarly used by care workers to increase the value of their care. As Kusimba (2020) notes, the management of rights-in-people can enable continued hierarchy and domination. Rights-in-people is a contested terrain and these contestations largely revolve around care. Our fieldwork shows how people are acutely aware of the provision of food, promises of inheritance, and salaries, all of which can be forms of domination that require recipients to provide care. We find that a rights-in-people perspective is a particularly useful lens to understand the relationship between care and economy. It is a theory of value that considers how people are part of complex transactional networks that reflect global inequalities and that, at the same time, also provides insight into the decisions that people make regarding providing or withholding care.
Commensurability
The previous sections have outlined ways in which people make economics and care commensurate with one another, weighing the value of care through different economic metrics. This commensurability is sometimes refused. In the case below, it was denied in order to enable a particular kind of commensurability between finances and care to occur, resulting in the death of the care recipient.
A Brazilian lawyer explained to Erik how precarious and complex the relationship between care and economics can be. A client of his started to have financial problems after her husband was hospitalized with a coma for several months. His client had a collective health insurance policy that, unlike individual policies, offers relatively little protection against increased premiums, changing policy conditions, or unilateral termination of the contract. The insurance policy was offered through the client's workplace, a small company with only a few employees. When it was time to reevaluate the policy, the insurer decided to drastically increase the premium. Several colleagues were shocked by the increase, and one of them contacted the insurer for an explanation. The insurer explained that their collective health insurance had one colleague with very high healthcare costs and that they had to increase the premium. The colleagues immediately realized that this was due to their colleague's comatose husband and, although they felt sorry for her, they also expressed their concerns to her about not being able to afford the insurance premiums. Brazil has a public healthcare system called Sistema Único de Saúde (SUS) but relying on SUS alone would mean that access to healthcare would become more difficult due to the limited resources and sometimes long waiting lists for treatments.
Due to the premium increase and financial problems due to the loss of her husband's salary, the client had to discontinue the insurance policy. This, however, meant that the hospital started sending the bills directly to her. The client was already in financial difficulties, and she became ever more desperate, faced with mounting debts. She was exhausted from visiting her husband in the hospital and discussed several legal options with her lawyer. In addition to the legal options, the lawyer suggested that she simply stop paying the hospital bills and visiting her husband in the hospital. He assured her that the problem would be resolved. According to the lawyer, she had the courage to follow through on this suggestion; not much later, she received a message from the hospital that her husband had passed away. The lawyer was convinced that the hospital had stopped giving life support to the patient, because of the lack of payment and visits. He felt that this was the right decision given that the husband was in a coma for months without a hope of recovery while creating a tremendous financial and emotional burden on his client. Ending life support was not discussed openly. The financial costs of care, and equating the moral and economic value of life, were not part of the conversation that the doctor had with the patient's wife, nor did the lawyer explicitly mention it in the conversation with his client.
This situation brings to the fore how precarious the incommensurability of finance and care can be. Commensurability was evident in several ways: health insurance premiums increased when care demands increased. The hospital sent bills, first to the insurer and, when that was no longer possible, to the patient's wife. The advice of the lawyer also pointed to the commensurability of life and finance, suggesting that the ‘price’ that his client had to pay for maintaining a comatose husband was too high. But the commensurability was at the same time precarious morally (see also Guyer, 2004; Henig, 2019; Lambek, 2008). As the lawyer made clear during his conversation with Erik, one is not expected to talk and think about healthcare in this way. One is not expected to equate the value of life with a certain amount of money but, the lawyer cynically pointed out, in the end, economic value is always at stake.
Towards a new language
Capitalism does not deterministically affect care-related problems. Global capitalism is diverse and variable, comprising a variety of economic relationships, discourses, and narratives. Capitalism can undermine as well as support care, through health insurance and paid care, for example, suggesting that there is no clear or linear relationship between care and the market. In addition, capitalism is dependent on non-capitalist economic exchanges and rationalities like gifts (Gibson-Graham, 2006; Tsing, 2013), such that paid care workers can expect an inheritance. Capitalism is also dependent on mutuality and solidarity (Bähre, 2020a; Gudeman, 2015), both of which play a crucial role in the financing and organizing of care in contemporary societies.
A too narrow focus on capitalism as undermining care relations has several consequences that obfuscate the complexities of the economics of care. For instance, a fundamental problem of human existence is that people get sick and die, for all kinds of reasons. Death is not simply due to capitalism, but also to the limits of human life. There is no way to measure what sufficient care is, so the definition of good care creates a host of dilemmas and uncertainties. What is health worth and to whom? What is a life worth? These fundamental uncertainties cannot be reduced to a single cause.
Focusing on multiple economic repertoires is more productive than trying to identify one fundamental cause like capitalism or neoliberalism as an overdetermining force (Guyer, 2004). Empirically, the cases and vignettes show that capitalism and neoliberalism do play a significant role in care arrangements. These repertoires also offer insight into the ways that the incommensurability of economic and other values are mobilized in care relations and in specific situations. Not every moral value is converted into an economic value, but sometimes morality is discussed using economic repertoires. Through these incommensurabilities of values, we see human creativity and therefore also agency (Lambek, 2008) in the face of challenging moments. In some situations, not caring can be a form of empowerment, liberating women from the burden of care. Since personhood is made in relation to others, these economic repertoires position individuals in relation to others in particular ways, allowing them to resolve, manage, and interpret the care dilemmas they face.
We have suggested several economic repertoires by which people make sense of the relationship between the economy and care as a productive method for not falling into a hostile-world framework; that is, for avoiding universalizing economic dynamics and ideologies that pit care and economies against one another. Our list is neither exhaustive nor complete but is a first attempt at making an inventory that does justice to the situatedness of ethnographic theory and at the same time provides a conceptual language that transcends that situatedness. We found that zero-sum thinking, notions about sacrifice and obligations, as well as rights-in-people, are persuasive registers that people draw on or mobilise when confronted with care dilemmas and the commensurabilities of values. Zero-sum thinking, notions about sacrifice and obligations, and rights-in-people are economic repertoires that reveal dilemmas and uncertainties about the economy and about care. Their value, we think, lies in that they reveal the commensurabilities as well as incommensurabilities of care and the economy and therefore offer an analytical path out of an approach that pits care against capitalism or relies on similar dualities.
Our approach may be a starting point for a further expansion of a vocabulary that analyses the care-economy nexus. It might also be useful in other domains beyond care. For example, economic repertoires might be deployed in discussions of environmental sustainability and green finance, where nature has a similar valence to care and dilemmas regarding commensurability also exist. A focus on economic repertoires is productive for understanding how individuals navigate dilemmas that avoid deterministic and limiting analyses of capitalism by attending to how those dilemmas are situated.
Footnotes
Acknowledgements
We deeply appreciate the comments by the reviewers and the journal editors, which we used to improve the paper. We are immensely grateful to all our interlocutors for their perspectives and interpretations.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the H2020 European Research Council, Wenner-Gren Foundation, Rutgers, The State University of New Jersey, and National Science Foundation (Grant Number 682467).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.