Affect, infrastructure, and vulnerability

Making and breaking Japanese eldercare

Jason Danely

13 Sep 2016

Abstract

Care work requires a vulnerability and ethical responsiveness towards the cared-for, including an openness to ebbs and flows of affective intensity. For care workers, affective vulnerability is not only a precondition for good care but can also precipitate exhaustion, neglect, and even violence under precarious political and economic conditions. I argue that the concept of vulnerability allows us to trouble the distinction between the supposed oppositional forces of care and violence, allowing us to imagine other possible ways of being in the world with others. Drawing on ten months of fieldwork in Kyoto, Japan, I describe how care workers constitute a human infrastructure whose vulnerability facilitates flows of compassion and cruelty, erotic intensity and heavy fatigue. Care workers’ narratives reveal a process of striving to embody vulnerability and sustain moral selfhood without breaking down.

Introduction

Visitors to Kyoto often remark on the scrupulous care taken to keep the city streets clean. This is particularly remarkable given the ubiquity of excessive packaging, convenience stores, and the lack of trash receptacles in most public places.[note 1]For more on the social anthropology of trash in Japan, see Gavin Whitelaw’s (2014) ethnographic study of convenience store waste. This a good example of the way moral values, infrastructures, and capitalism produce patterns of consumption and the management of loss that resonate with other manifestations of what I call the ‘politics of well-being’.
 Japanese city residents pack away bundles of trash in purses and backpacks, tuck cigarette butts into neat portable ashtrays, and stroll the riversides and parks in teams of cotton-gloved volunteers, picking up litter.

In most neighbourhoods, proper disposal of household garbage is a meticulously ordered and collectively monitored task: waste items must be first separated into burnable and non-burnable trash, sealed in the correct type of municipal plastic bags, brought outside on the morning of collection to designated sites, and then safeguarded from the interference of crows by covering the sacks in protective netting. Improper separation of trash or broken bags results in trash being left behind by collectors, and the household responsible is made aware of their irresponsible behaviour. Most of the time, however, the household charged with monitoring the collection point tidies up beforehand.

For several months during my last period of fieldwork in Kyoto, the garbage monitor for the collection site where I would take my bags was Matsuda-san,[note 2]All names used in this article are pseudonyms, and in some cases personal information is altered to protect identities.
 an eighty-five-year-old woman with boyishly cut grey hair and a perpetual gentle smile. She lived with her son and daughter-in-law in a narrow three-storey house across the street from mine.

Figure 1. Where are the older people? A day-service van making the morning rounds in a Kyoto neighbourhood.Figure 1. Where are the older people? A day-service van making the morning rounds in a Kyoto neighbourhood.

Twice a week, after our garbage bags had been safely tucked under their netting, Matsuda-san would wait at her door for one of the many white minivans that glide through the city each morning to take her to a local ‘day-service centre’. Day-service is one of the most common basic care services for community-dwelling older adults, providing baths, meals, exercise, and social activities, and respite for family caregivers. The white van would stop just outside and men or women dressed in white polo shirts and blue tracksuit pants would hop out and greet her with cheery voices, then guide her up slowly into the back of the van where one or two other women would be seated.

The same aesthetic of efficiency and attentiveness to the ‘public eye’ (seken no me) that marked garbage collection was evident in the way fleets of white vans swept through the city each day, going to and from dozens of hospitals, rehabilitation centres, day-service centres, and short-stay facilities. They had the uneasy effect of making the presence of care-dependent older people both mobile and contained, recognizable yet masked. The vans assured that the bounds of social life would be limited to the home and the centre, where a clearly delineated content of care could be measured and enforced.[note 3]Ingold (2011, 56) describes a distinction between what he calls ‘transport’ and ‘wayfaring’, arguing that the two produce different kinds of knowledge about the world. Put simply, transport has a clearly defined destination and route that does not deviate, while wayfaring produces knowledge that is more processual, contextual, and uncertain. In this way, the physical and administrative sides of care can come into conflict with the everyday affection and responsiveness of care work. See also Mol’s (2008) distinction between the ‘logic of choice’ and the ‘logic of care’.
 Perhaps it was just the coincidental juxtaposition of waste removal and elder removal that made me feel uneasy as I waved goodbye.

When the subject of the white vans arose in a conversation I had with a former day-service employee, she was quick to affirm my sense of unease. ‘One in four Japanese people are over 65’, she began, ‘but where are they? You don’t see them because those white vans come around, and some guy in a tracksuit comes out and kidnaps them! It’s just like most Japanese want to hide them away’.

Similar statements were made as I spoke with more and more people involved in the extensive Japanese eldercare service industry, a rapidly expanding array of nonprofit organizations, for-profit enterprises, and government services, linked through various mediating agents such as local comprehensive care centres,[note 4]Comprehensive community support centres (chiiki hōkatsu shien sentā) were introduced in 2005. Staff at these centres are responsible for organizing smaller community-based organizations and volunteer groups, but are also involved in delivering social care services directly.
 licensed care managers, and neighbourhood volunteer groups. These entities do not constitute a unified and cohesive system (as any who have tried to navigate through the Japanese eldercare maze know all too well), but are better described as assemblages pulled together into the complex realm of market-based relations and subjectivities that broadly constitute welfare as a politics of well-being.[note 5]Hromadžić (2015, 4) provocatively describes these assemblages in postwar Bosnia-Herzegovina as ‘uneven and multiple, politically and socially generated semi-absences’ where we ‘can begin to grasp the terrain of aging and care as fundamental dimensions of political and social practice’. These semi-absences are produced during the ‘reshuffling of the postwar and postsocialist assemblage of care’, which Hromadžić (2015, 8) argues reveals ‘ruptures, ideologies, and myths about delivering care, past and present’.

Within this context, I suggest that the rapidly growing ranks of eldercare staff (kaigo shokuin) constitute a human infrastructure of the politics of well-being. Eldercare staff embody and circulate the affective flows essential for sustaining their work as both moral and meaningful, and yet the vulnerability and intimate empathic engagements that facilitate these flows channel other affective tones as well: violent, erotic, exhausted. These are not the typical feelings that we might associate with good eldercare, but they reflect the conditions and challenges of care workers and others involved in the messy tasks of handling human bodies and feelings in Japan’s ageing society. Care worker narratives reveal complex ethical choices, emotional vulnerability, and the duplicitous nature of care in a late-capitalist welfare economy.

Care work has the characteristics of other precarious labour in late-capitalist societies: low paid; insecure in that it relies on part-time, flexible contracts; emotionally strenuous with high rates of depression and burnout; staffed by a disproportionate number of women compared to other sectors; and low status (Allison 2013; Broadbent 2014). But to look only at the conditions of care work risks closing the aperture too tightly, limiting our view to the particularity of care workers themselves. In contrast, by considering their case as an application of anthropological theories of infrastructure, I suggest that we come closer to understanding how affects, ordinary and otherwise (Massumi 2002; Stewart 2007), move and create a sense of coherence from assemblages of elder care.

Larkin (2013, 329) describes infrastructures as ‘matter that enable[s] the movement of other matter’. The infrastructure of eldercare and other affective labour, therefore, depends not only on the movement of ‘matter’ but, more importantly, on the movement of ‘mattering’ (Lynch 2013). Just like any other ‘matter’, affects move and are moveable as they animate interactions. By attending to the feelings of those being cared for, care workers move affects, and in doing so, they shape social relationships and capacities for well-being. In describing care workers as a human infrastructure, I do not mean to suggest that they are merely analogous to conduits or pipelines in their role of care ‘delivery’; instead, they also move and are moved, just as Matsuda-san moves to the day-service, nurses visit patients in their homes, and care workers burn out or change jobs.

Care work involves an ongoing process of translating values and transforming subjectivities. Through care work, workers translate the value of sustaining ‘life’, as one of the broad moral aims of social welfare, into feelings of well-being for individual older care recipients. This translation, which requires skills of attentiveness and empathic sensitivity, produces transformations of the self (Mattingly 2014). Care workers are aware that, at times, the administrative and regulatory frameworks that systematize eldercare work as welfare must be set aside for the sake of well-being. The ways they interface with formal biopolitical structures, materializations (the technologies, regulations, and ideologies that inform them), and the lived experiences and bodies of the cared-for means that care workers are constantly involved in translating and interpreting their feelings and their ethical and subjective positions in relation to a politics of well-being. Care workers’ subjectivities cannot be reduced to the biopolitical policies that structure their work any more than the lives of the cared-for can be reduced to the mechanisms of their care.

The lives of care workers have been examined elsewhere (Brodwin 2013; Buch 2013, 2014; Kavedžija 2015; Mazus 2013; Rapport 2007; Stacey 2011), and my work echoes many of the findings of these previous studies, as I describe how care workers mobilize creative strategies, personal meanings, and revaluations of well-being for themselves and others. They do this in spite of and sometimes at the cost of debilitating emotional and physical demands, and while being subject to poor working conditions. As others have argued, care workers should not be seen as martyrs, nor as mere agents of biopolitical sovereignty, yet their lives are animated, intensified, and captured in various ways by both of these narratives.

Fieldwork

Japan has the highest proportion of older adults (those aged sixty-five and older) of any country in the world. As the fertility rate continues to stay well below replacement levels, it is expected that by 2030, one person aged sixty-five and older will be supported by only two working-age persons, compared with 1960, when one was supported by slightly more than eleven (Muramatsu and Akiyama 2011, 426). Since 2013, sales of adult diapers have surpassed those for infants, and the number of day-service centres now rivals that of convenience stores. In order to better understand the implications of such rapid and historically unprecedented population ageing on political, economic, and gendered subjectivity, I examine the narratives of current and former care workers, paying particular attention to embodied affect, moral translations, and subjectivity transformations.

I conducted ten months of fieldwork in Kyoto, Japan’s seventh-largest city by population, between 2013–2014. Although my primary focus during this time was family carers, the ethnographic material I present here is based on interviews I conducted with twenty-five care workers, only five of whom were men. I use the term ‘care worker’ (kaigo shokuin) to cover a broad range of occupations related to eldercare. I do not mean to make a sharp distinction, as some do, between ‘work’ and ‘labour’ (see Arendt 1958), nor do I wish to imply that unpaid carers (see Brijnath 2014), such as family members or volunteers, are not engaging in some kind of ‘work’. While the care workers I describe are involved in a certain kind of ‘affective labour’ (Hardt and Negri 2001), the self-transformations involved in the process of care also entail the ‘work of the self’ (Parish 2008, xii) and the ‘work of culture’ (Obeyesekere 1990). Furthermore, many of the care workers also had personal experiences as unpaid carers or contributed to volunteer programs as well, so it would be reductive to label them according to an occupational category, such as ‘formal’, ‘professional’, or ‘paid’.

Most, but not all, of these care workers held certificates in some aspect of geriatric care (kaigo) or welfare (fukushi). Three of the care workers I spoke with were nurses with experience in both geriatric hospital settings and home visits. Others included home helpers, day-service employees, care home directors, care managers, and social workers. I also spent two to three days each week conducting participant observation and speaking with people in several different group care settings (group homes, day service, food delivery, and carer support groups).

To gather a wide range of representations of affectivity in care work, I collected images and texts that appeared in popular media and advertisements recruiting care workers. These representations brought in another aesthetic dimension to my analysis that highlighted gendered and life-course related aspects of care work in Japan.

In collecting and analysing these narratives and observations, it was clear that experiences and attitudes toward eldercare were extremely complex and varied. While abuse and exploitation are serious and real, they are but one aspect, and care work is also moral and meaningful work. Both aspects deserve our critical attention and understanding. 

Vulnerability

The expression of vulnerability makes the I vulnerable for the other’s vulnerability.

                                                                                                  – Per Nortvedt (2003, 227)

The forces of compassion and violence pervade the politics of well-being, and rather than map each of these moral orientations onto wholly separate entities (the carer and the bureaucratic institutions or discourses they contend with), I hope instead to show how both arise from a fundamental orientation toward vulnerability. The same sense of brokenness that compels one to feel compassion for the suffering of another person also exposes one to fear and aggressive acts. In making this claim, my analysis of carer narratives draws less on anthropological accounts of the formation and reproduction of subjectivities through neoliberal forms of governmentality, as inspired by the work of Foucault (see, for example, Muehlebach 2011) and more extensively on phenomenological and existential approaches to what Lambek (2010) calls the ‘ethics of the ordinary’ and what Mattingly (2014) describes as the everyday spaces of ‘moral laboratories’. These approaches foreground the roles of narrative selves in projects of moral becoming and the ways experiences of suffering and care bring about openness, vulnerability, and potential (Butler 2004; Das and Han 2015; Stevenson 2014). Looking at care work in this way provides a conceptual link between the everyday, emergent tension, exhaustion, and stimulation of attending to the care of older people, and the experimental struggle of becoming moral in a way that can be recognized as both human and humane.

Care as vulnerability condenses the ethical recognition of and responsibility for the other, a recognition that is grounded in the body and its sensibilities (Nortvedt 2003, 228; Rapport 2015). One line of theories of care as an ethical response to vulnerability derives from the philosophy of Emmanuel Levinas, which Pinchevski (2012, 345) notes, rests on ‘the fundamental experience of subjectivity vis-a-vis the Other’. Levinas’s ethics of the everyday, the ethics in the face of the Other’s alterity, brings one beyond reason and even language, to a transcendent ‘response-ability’, or the possibility to be ‘called upon and to respond’ (Pinchevski 2012, 346–47). Altez-Albela (2011, 37) writes that, for Levinas, the body and its sensibilities present an ‘affective attitude towards the “horizons”’, and the possibility of transcendence and ethical response to the Other. Butler (2004) also reminds us that Levinas’s ethics also contends with the precariousness of both self and Other, and the ‘struggle to keep fear and anxiety from turning into murderous action’.

Paying attention and empathically responding to the needs of the cared-for makes the carer vulnerable in the sense that it requires putting aside one’s own feelings for the sake of the other, even when doing so risks exposure to uncomfortable sensations and social exclusion.Like other forms of infrastructure, care work fulfils a critical social function in ways that are often invisible to society, but which, when revealed, are considered dirty (in the sense of being both polluting and perverse). One manager of a small, multifunction group home,[note 6]Small, multifunction group homes (shōkibo takinō kaigo shisetsu) aim for personalized care that overlaps home visits, stays in a group home, and day-care respite. They are flexible to the needs of each person, rather than being an all-or-nothing (completely residential care or completely ‘community-based’ care) facility.
 for example, recalled that when she told her mother about her plans to work in eldercare, the response was, ‘why would you go to all that schooling just to become a diaper changer?’ These common references to eldercare as work ‘beneath the belt’ underline this condition of vulnerability, carrying connotations of both shit and sex, of an obscene babying of an adult stranger’s body (Twigg 2000; Twigg et al. 2011, 172).[note 7]While diapering itself is not overtly sexual, the ambiguity of caring for ‘underparts’ (shimo no sewa) has an uncomfortable association with sex when it comes to paid work between men and women. The fluidity between caring and sexually stimulating touch is elaborated later in this article.
 Like the garbage collectors, care workers clean and dispose of bodily waste, and, in the end, the body itself.

Against this backdrop, care workers strive to maintain dignity through narratives of moral worth. They not only do the ‘dirty work’, but they do it with affection and care that exceeds their structural role. It is the affective and meaning-infused aspect of care work that initiates creative resistance to their own subjectification as mere ‘diaper changers’. One home care geriatric nurse who worked in some of the poorer areas of the city described her deviation from policy with rebellious humour:

We can’t just follow the policy. That wouldn’t do any good… . There has to be some overlap between what the person needs and what is in our job description. If it says that we have to care for only one client, and there is another person that needs help in the household, we might take a look at them too. For example, I have a client who is eighty-five and she lives with her eighty-nine-year-old husband. He is not my client, but whenever I go over there, she asks if I can look at him too. He doesn’t have a nurse because they can’t pay for it. So of course I’ll take a look. Or I’ll go in and I should just be giving nursing care, but they have a home helper coming in on alternate days, and they can’t really make any decent food for themselves. So maybe I’ll put up the laundry or wash and make some rice for them [giggling]. Really, I shouldn’t be doing that, but if I don’t, what’s going to happen to their health? So I’ll do a little something like that. It is kind of fun, actually. Everyone does that really. You have to. You can’t just follow policy and care for the whole person. You can’t just say, it’s thirty minutes! I have to go! That’s not being human.

When I asked, in response, ‘But can you spend that kind of time with people and do your job?’, she said, ‘Hmmm, well I don’t think you can always do it’.

This excess of care, while a part of the narrative of the carer’s moral identity (‘being human’) and a part of the trust-building essential for patient/client satisfaction (Buch 2014, 602), also heightens the worker’s vulnerability within the politics of well-being. In some sense, this nurse illustrates the ‘tinkering’ Mol (2008) describes in contrast to the logic of choice in medicine. If care involves recognition of the ‘whole person’, such tinkering resists the dismembering functions of care plans and guidelines (which are put in place for the purpose of protecting patients). Nurses who care for the ‘whole person’ in order to ‘be human’ in this way also risk emotional attachments, fatigue, and reprimand; they risk vulnerability of the I ‘for the other’s vulnerability’. Yet we might also ask: Where else might one have the opportunity to ‘be human’ than in these spaces of suffering and vulnerability? Where else might one fully sense the force of life in this way?

Precariousness and affect

Care workers are not only vulnerable in the Levinasian sense of facing the dependent being of the cared-for – not only vulnerable ‘for the other’s vulnerability’ – but they are also vulnerable because their work is precarious. One employee at a day-service centre pointed out that not only was he working in precarious conditions, but he found himself there because of unstable conditions in his previous work. When I asked him how he ended up as a care worker, he explained, ‘Care institutions are scrap piles!’ The word he used was ‘hakidame’, and he explained with the image of scraps that get swept into the corner. To call oneself ‘hakidame’ is only a personal admission of a sense of social and moral failure, of care work as a status that already indicates a life that didn’t go as planned, but also points to the more widespread condition of flexible labour that has become prevalent in postrecession Japan (Allison 2013, 7).

The ‘scrap pile’ is not limited to those who lack education or for some reason have opted out of mainstream society. Care workers were sometimes former factory workers, restructured out of the shrinking manufacturing industries (retrained to work in care homes under the logic that such work was not very different from other manual labour); others I met were former farmers or retail workers who came to work in care settings after moving to the city. Other care workers were women who were encouraged to become carers as a way of rejoining the workforce. One poster displayed outside a home care agency featured a woman in a clean nurse’s aide uniform, her badge hanging from a lanyard around her neck, holding her son’s hand as he smiles and cheers her on with, ‘Do your best Mom!’ Beneath them, a tagline reads ‘Once more, let’s begin here’. While returning to work after starting a family is often difficult for women in Japan, care work ads like these address mothers as ideal candidates. As of 2015, 95 percent of nurses in Japan were women, with similar proportion for home visit care workers (hōmon kaigoin, or ‘home helpers’). In nearly all categories, but especially in part-time, low-paid care work, the large majority of care workers are women (Broadbent 2014). 

Figure 2. ‘Do your best, Mom!’ A poster advertising jobs in nursing care.Figure 2. ‘Do your best, Mom!’ A poster advertising jobs in nursing care.

My friend who made the comment about ‘scrap piles’ held a postgraduate degree in biology from a US university. He was hardly the type one might expect to fall into the scrap pile. Yet after struggling to move forward as a researcher, first in America, then in Japan, he became disenchanted with the high pressure and some of the unethical practices he saw going on around him. After a falling-out with the director of his lab (and some other unfortunate personal circumstances), he decided to revise his CV once again, taking a job first at a geriatric psychiatric hospital and later in day-service. ‘I didn’t think I’d end up doing this for so long’, he told me, ‘But I didn’t have a lot of options, and it was kind of depressing. I like it a little more now, but I don’t know how long I’ll keep going. My last job – I just walked out without even telling anyone that I quit. I still feel a little bad about that. But with this job, they didn’t even care [that I quit that way]’.

This care worker’s case highlights the ways precarious employment in other occupational sectors funnels labour into the rapidly growing ranks of care workers who tend to Japan’s ageing population. The booming market for jobs in caregiving coincided largely with the privatization of the welfare service sector following the neoliberal reforms of the Koizumi era (2001–2006), and the implementation of the long-term care insurance system (2000–present). Between 2000 and 2015, the number of employed care workers rose from 549,000 to over 1.4 million (Ministry of Health, Labour, and Welfare [MHLW] 2012). Remarkable as this is, demographers predict that in another ten years, between 2.3 and 2.5 million care workers will be needed in Japan, which, at current estimates, will likely produce a shortfall of at least three hundred thousand care workers (Suzuki 2015). Given the constant demand and low bar for training (a short course for basic certification can be completed in a couple of months), care work not only picks up the leftovers from other industries, but can also exploit those who are unlikely to rejoin the ranks of full-time employment (such as mothers who left jobs to raise children), those already employed in other areas of the irregular service sector (such as supermarket staff or sanitation workers), or those who have few options because of their past history (such as ex-offenders[note 8]Several Japanese prisons offer training as a ‘home helper’ for older adults, including Fuchū Prison, one of the largest in Japan.
 and people with mental health problems).

The rate of turnover for care workers in the first three years of employment is between 32 and 35 percent (Kaigo Rōdō Antei Sentā 2015). Given the physical and emotional demands of the work and the poor conditions (low pay, uncompensated overtime, irregular hours, et cetera) those who have not had extensive training, and who enter into care work primarily because they could not find or hold onto work elsewhere, are at high risk of burnout. Several care workers spoke frankly about what they saw as higher than usual rates of depression, heavy drinking, and erratic behaviour among their colleagues. The risk of emotional distress thus manifests in the very bodies of those charged with comforting others, yet interestingly, it is the affective power of care work, its unique ability to intensify a sense of authentic, strong emotions, that is sometimes held up as one of the attractive and meaningful qualities of the job. One advertisement for home visiting nurses, for instance, pictured a young, starry-eyed carer set against an amber soaked sunset with the tagline ‘Crying, laughing, the sun sinks down – will you strive to be even better tomorrow?’ 

Figure 3. ‘Crying, laughing, the sun sinks down’. Advertisement for in-home care workers depicts care work as both gendered and emotionally rewardingFigure 3. ‘Crying, laughing, the sun sinks down’. Advertisement for in-home care workers depicts care work as both gendered and emotionally rewarding

For many who find themselves adrift and without a sense of vocation, the opportunity to find meaningful work that opens one up to emotional challenge and growth is seductive. Here, the vulnerable leverage their vulnerability into a form of self-making that depends upon the worker’s own openness to the cared-for, to the mutual responsiveness and cultivation of empathic imagination. To be vulnerable through the experience of care work is at once the risk and promise of well-being; it is a chance to become an ethical subject, to ‘be good’ and to ‘do good’. So while it is important to critique the political and economic forces that have produced the ‘scrap pile’, it is also important to bear in mind that this vulnerability provides an existential ground for aspirations and alternate forms of well-being to be imagined. This might lead to something more than simply other modes of subjectification and violence, but could also produce ruptures in the ‘flow of ordinary work’, permitting a productive reflection on ethics (Brodwin 2013).

Violence

I have been describing vulnerability within two different sets of relationships: the vulnerability that constitutes a ground for empathic imagination between care workers and care recipients, and the vulnerability of livelihood as a care worker in the politics of well-being. My argument has been that the care worker is simultaneously interpellated through both of these intertwining vectors, one hopeful, the other devastating, one of compassion, another of violence. Both, I suggest, produce affective responses – attention and attachments – as care workers compose moral self narratives and struggle with precarious conditions, and these affective responses flow through their bodies and voices as they enact care.

The gap between care policy and the work of care manifests at times in a dangerous excess, and at others as dangerous scarcity, neglect, and abuse. Care workers are vulnerable to fatigue just as the care system as a whole is punctured with deficiencies. Just as systems of care also produce violence through a kind of selective recognition (Povinelli 2010; Stevenson 2014), individual care workers contending with fatigue and stress participate in degrading and violent acts in the names of care.

Before she began making home visits, Wada-san worked in a geriatric psychiatric hospital. In the hospital, care was provided through the general medical care system rather than long-term care insurance, and with an entirely different but no less constrictive set of rules and procedures. The biopolitics of bare life was palpable in her descriptions of the hospital, both for carer and cared-for:

Wada: If you have one person for nine patients, and one of them is making a noise or being restless, what are you going to do for the other eight? What can you do in those situations? You can’t do anything. It’s impossible.

JD: And drugs?

Wada: Oh my, all the time! If one patient was a little out of hand, a male nurse would come by right away with a little syringe and that would be it.

JD: Did they separate the older patients with cognitive impairment, like dementia?

Wada: No. They were all together. Schizophrenia or psychosis or whatever. Only they separated the more severe cases from the mild ones. The severe cases would get solitary locked rooms. But they were in the medical care system, so they didn’t have to follow the long-term care guidelines or anything… . So that’s why they can do things like tie them up.

JD: It’s exhausting work?

Wada: It’s full of exhausting things [tsukareru koto darake]. Hard, emotional work. I hoped that I could do it more happily, but – you have to pay attention to your coworkers, pay attention to the patients, pay attention to the family, pay attention to yourself, pay attention to the doctor. 

A constant attentiveness to both the needs of the suffering and the condition of suffering itself (especially when one’s own actions are contributing to that suffering) rubs the skin raw for even the well-trained staff. Here violence, numbing sedatives, and restraints do not constitute a resistance to care, but are extensions of it. Care must be stretched, extended, since carers are so few and sufferers so many. In this lopsided equation, the affective connection between co-sufferers materializes in the shared participation in the ‘wound’ of the other’s vulnerability. ‘Violence’, one Japanese social worker told me in a dry, matter-of-fact way, ‘is always the flipside of care, like two sides of the same coin’.

In 2013, there were 16,140 reported cases of elder abuse in Japan (up 3.9 percent from the previous year). While most of these occurred in private homes, neglect and abuse were also prevalent in long-term care insurance facilities: 221 cases, up 42.6 percent from the previous year, and the highest since the Elder Abuse Act was passed in 2006 (MHLW 2015). This type of violence is not, however, as rare as it may seem from the statistics. Often it merely takes the form of neglect, but within the precarious space of the care home, even neglect is sometimes seen as an ethical decision to spend one’s limited resource of attention in an efficient way. Ando-san, who worked in a short-stay facility, explained that self-preservation sometimes meant making a hard choice between care and neglect: ‘Care work, well, take for example, if you have a really nasty – nasty is a little rude of me, but – a client who really takes a lot of work. But even if you have someone like that, you just have to put up with them for eight hours and at the end of eight hours you can go home. You just say [to the next shift], can you take care of him?’

As Ando-san told me about having to make these choices in his work, he appeared increasingly anxious, as if betrayed by the politics of well-being. The choice to neglect patients, while rationalized as an ethical obligation to attend to other patients, nonetheless haunted many care workers. There were vivid stories of leaving a disruptive older person in a soiled and stinking diaper all day, or having to restrain an agitated dementia sufferer in order to force her into a bath. Care workers also experience frequent verbal, physical, and sexual abuse from patients.[note 9]While there is still little research on this subject, one survey in Hyogo Prefecture (Sankei West 2016) found that half of all visiting geriatric nurses have experienced aggression (bōryoku) from either the older person they cared for (70 percent of cases) or that person’s family.
 Everyone had experienced violence, even as they experienced care, and both were related to vulnerability and the affective dimensions of the politics of well-being.

Butler (2004, 20) writes, ‘Loss and vulnerability seem to follow from our being socially constituted bodies, attached to others, at risk of losing those attachments, exposed to others, at risk of violence by virtue of that exposure’. If vulnerability, as Butler notes, is fundamentally a state of ‘exposure’, or what Levinas referred to as the ‘face’, then this visibility needs to be positioned in relation to the invisible. A common feature of infrastructures is that they are hidden, naturalized, or unremarkable until they break. And so rather than viewing violent incidents as sudden or anomalous, they are already implied in the vulnerability of care relations.

Like the garbage bags left out to shame a careless neighbour, their sickening private contents sometimes torn apart and strewn across the street by crows, care workers’ vulnerability can erupt into an untidy and embarrassing scene. Every day such scenes are quickly cleaned up once again, with the older people of Japan again behind doors, rendered invisible deep within space where the infrastructures of care guide them.

Erotic

Violence in care settings in linked as well to the sensuality and intensity of its erotic, pleasurable experiences. Both hinge on the hypervigilance towards intimate bodily encounters, the comforts and anxieties that emerge in the experience of the body as exposed, excitable, and exciting. Some anthropologists have started to take an interest in sexuality and erotic pleasure not only as a characteristic maintained into older adulthood (Edmonds 2014; Moore 2010) but also as a component of physical and emotional care (Koch 2014; Kulick and Rydström 2015; Miyoshi and Serizawa 2003; Nakamura 2014). As Japan’s population ages, there has been an increased demand for niche pornography set either in nursing homes or in erotic situations between an elderly man and his daughter-in-law/carer. Such fantasies play on intensified gender roles and power dynamics that pervade the politics of well-being in Japan, and, as with cases of violence, their infrastructural presence is rendered invisible by both material structures (institutions and private homes) and feelings (disgust, shame, shock). In this section, I examine the way the erotic aspects of care become entangled with vulnerability and affective experiences of bodily capacity and exhaustion.

Before delving directly into the erotics of care, I think it is worth describing some of the context by which the connection between care, violence, and the erotic came to my attention. One day, as I was having coffee with some unpaid carers at a local café, Tamura-san, a care worker and another regular at the café burst in, his thinning black hair wild, a look of disgust on his face. Tamura-san had been working as an aide in a care home for less than a year, having cared for his mother at home prior to that. ‘I have to go to court’, he said, incensed. Cooling down, he explained that he had just quit his job because of the frequency of abuses that he saw there. The owners, he explained, had borrowed money from illicit lenders to start the home, and weren’t willing to expose any abuses for fear of getting into danger with the yakuza (a term used colloquially for Japanese organized crime, bōryokudan).

When these stories arose, no one rose to deny or refute them. Tamura-san explained that the owners were able to get a permit to run the business very quickly because they classified it as a ‘disability care centre’ rather than one specifically for the elderly. Government support programs paid for vehicles (the ubiquitous white vans), and inexperienced and untrained staff were hastily put on the payroll. ‘Families know that the abuses are happening’, Tamura-san said in a voice both pitying and angry, ‘but they ignored it. They just don’t want to look at it’. When I asked if there was oversight or audits of the institutions he brushed it off: ‘The city doesn’t have time to really audit all the institutions. They come around once every three years, and even if you have a violation, they still don’t shut you down anyway, so no one really pays attention. Some of the staff that were the worst [offenders] left the job, but then they just got jobs at other care homes’.  

Care homes and other businesses that systematically violate Japanese labour rules, such as withholding compensation or condoning abuse, are called ‘black companies’ and have been implicated in charges of various abuses of staff and clients alike. When I first began hearing rumours about these care facilities, I was sceptical. As I listened to more care workers, however, I began to see a link between black care homes and other kinds of labour that exploit physical intimacy, vulnerability, and care: erotic care work. While I do not have sufficient space here to fully develop this connection here, I do believe that a brief exploration of the erotics of care can shed light on affective associations between arousal and exhaustion, excitement and depletion in late-capitalist welfare societies.

Tamura-san’s ‘black care home’ was made possible with financing from an organized crime group. These groups are associated more often with the sex industry than with nursing, and yet both occupations perform what is seen as a valuable care service requiring attentiveness, physical touch, and vulnerability. Interestingly, sexual services in Japan often use the phonetic euphemism ‘health’ (he-rusu), as in ‘fashion health clubs’ or ‘health delivery’ (where a menu of sexual services are brought to the client) (Nakamura 2014). Both nursing care and sex work are industries dependent on an irregular workforce of women and both support dominant notions of masculinity. Finally, both are entwined in a politics of well-being, and, with a capitalist debt economy, facilitate the easy entry of black companies into eldercare. Even as Tamura-san continued his tirade about his lost job, another friend at the table interjected simply, ‘It’s like mizushōbai!’ (the world of the ‘water trade’, or erotic companionship work, Allison 1994).

While I did not personally meet any care workers who actually engaged in sexual services for clients (at least to my knowledge), care workers (both men and women) expressed times when they felt that they were perhaps inadvertently stimulating a client or patient in the process of lifting, bathing, or other everyday acts. A worker at a day-service centre, for example, told me that many of the female clients preferred to be bathed by particular male staff. ‘I guess for some of these people’, he reflected, ‘this is the one time each week where their body is touched by a man. I usually don’t mind, but it is just something that we don’t talk about’.

Kanada-san, a woman in her early forties, who, at the time of our first interview had just quit her job as a geriatric care nurse, was also very conscious of the ways her role as a carer blended into the erotic: 

Day after day, it’s what you might call ‘emotional labor’ [kanjō rōdō]. Not exactly the same kind of emotional labour that a hostess[note 10]Hostesses work as female companions to mainly male patrons of clubs and bars (Allison 1994). Sometimes compared to geisha, their work involves presenting an ideal feminine beauty and performing a kind of flirtatious affection that would be absent in marriages. Long-standing relationships sometimes develop, but there is no actual sex between hostesses and patrons.
 does, but close [laughs]. It is like hospitality, using a soft sweet voice, and things like that, it really tires me out… . For me, I think that hostess and nurses are in the same category. They both have to gauge feelings, the way they respond is virtually the same. I really felt that when I worked at a day service.

The soft erotics of affective labour perform vulnerability through playful vocalizations, touches, and feeling-work that creates an atmosphere of ‘hospitality’ within the hospital.[note 11]In Japan, as elsewhere, hospitals often developed from ‘hostels’ or inns along pilgrimage routes in medieval periods. These were also locations of brothels, and in Japan, where sex work had no sinful connotations, sacred sites often had explicit relationships with sex workers (conducting special rites for their protection and health for example) and pilgrims often combined a trip to sites like the great shrine at Ise with feasts in the Furuichi entertainment district.
  This work is sometimes referred to as ‘iyashi’, a kind of spiritual sustenance or ‘healing’ associated with care rather than cure, a relaxation of the body and mind (kokoro) that restores the ‘force of life’ (seimei no chikara).

While Kanada-san found this emotional work satisfying (indeed, the desire to comfort others remains her primary motivation for working in eldercare), she found it tiring when her emotions were not reciprocated or when families would not visit or chose palliative care. Kanada-san and the other staff believed that family members were dependent on pension income to pay off their own debts, and therefore kept incapacitated parents alive through feeding tubes and nursing care. The biopolitical management of life in the geriatric hospital and the agony of the slow death were intimately linked to economic precariousness outside, the same precarious conditions that, as mentioned above, contribute to risky employment in the care industries.

The medical apparatuses and administrative structures that sliced away at the lives of both staff and patient, degraded the soft erotics of caring, the sensuality and feeling that she describes as ‘life energy’, or ki :

Kanada: Watching the faces of those who are suffering in the middle of the night, left behind by their families. That’s the job of people like us who work in those places [genba]. It’s excruciating to see that. But those families have their circumstances, and so if I let them die, they’ll be in trouble. It’s miserable. Miserable [yarusenai]. I think, what am I doing here? In a kind of spiritual way you could say, it’s like these are people who are going to the other world, and we are preparing them to go, but we have to keep them alive [in the hospital]. It feels like [the patient] is sucking out my life energy. We have the word ki. Ki is the energy that we need to live. I really felt that.

JD: When you’re tired?

Kanada: Of course when I’m tired, but it’s more like, my feeling, how should I put it – it is like qigong. I think of it like a kind of air running through my spine. When I am with people who are well, I feel like I am charging up. It’s a really sensual feeling – but I get so tired. So tired. Even if I charge up somewhere else, when I come back, they just suck it right out of me again.

What struck me most about Kanada-san’s descriptions of ki was the way it was in continual circulation through her body and through the bodies of others, flowing in like electricity and being vampirically drained. These bodily exchanges seep across the porous skin of the embodied self, which is at once the medium of a soft-erotic healing encounter and a target, threatened by the ‘black’ and ‘miserable’ forces of debt, exploitation, illness, and old age.

Conclusion

I began this paper with the ordinary image of garbage bags and the women and men in the white vans. Both, I suggested, were part of the typical, everyday morning routine, the visible infrastructure of the moral values that motivate people to keep private, messy, and bothersome life controlled, hidden, and protected. Care workers are a vital component of this infrastructure, circulating affects through their attention, touch, and responsiveness to those they care for. Care work, at once tedious and meaningful, maintains a sense of well-being not only for older persons and their families, but for the entire social community and the care worker herself.

When a care worker described himself as a part of the ‘scrap pile’ of precarious affective labourers, I wonder if he had imagined the way even the scrap pile serves its purpose of ordering behaviours and attitudes and supporting well-being. Or perhaps he imagined the scraps strewn across the street after the crows had their way: broken, exposed, and shameful? Like other infrastructural processes, care work is both essential to the functioning of political-economic life and socially neglected. Care work is complicated in that the vulnerability that underlies its affective and ethical nature is also the source of its fragility. Likewise, material infrastructures like bridges or roads may crumble over time, causing injury and outrage, but exposure and vulnerability are also essential to their functioning.

As the cases I mentioned illustrate, carer subjectivity is formed in response to a politics of well-being, wherein the value of supporting life by creating good feelings in the suffering person becomes a staging ground for cultivating a meaningful sense of vulnerability, or what Nussbaum (1986, 86) calls ‘the peculiar beauty of human excellence’.  In this way, the everyday life of Japanese care workers, their ethical stumbles and recoveries, their vulnerability and uncertainty, reveals the contours of life’s force, its moments of disruption (Becker 1997) as well as its ‘eventful’ potential (Das 2006, 7) to share in and adapt the self in the face of the encounter with the pleasures and sufferings of others. I have tried to illustrate some of the ways embodiment and affect are shaped by this process of adaptation in the context of structurally precarious conditions.

Vulnerability allows the world, in all its tenderness and all its violence to happen to the carer. It creates intersubjective openings, intimate wounds that the force of life leaves unhealed, unconcealed, unsafe. This wound becomes the condition for the imagination of other forms of personally meaningful life, ‘existential power’ (Jackson 2002, 43; Rapport 2003, 3) and responsibility. When care workers make decisions to do what is ‘good’, what brings pleasure, what is ‘human’, they reroute the flow of this power and its capacity for well-being, exceeding biopolitics, in another vernacular imaginary of shared life.

The politics of well-being that produces Japan’s vast array of white vans and black care homes depend on management of affects, attention, and attachments. Care workers strive to contain affective intensities that the vulnerable encounter with the Other demands, even when to do so ‘breaks the rules’. Everyone agreed with this fact. The challenge was to break the rules without the rules breaking you.

Acknowledgements

I would like to express my gratitude to the Japan Society for the Promotion of Science and the Kokoro Research Center, Kyoto University, for their support during my fieldwork in Japan. I would also like to thank Malini Sur and Sidharthan Maunaguru for organizing the workshop ‘Force of Life: Living in Precarious Spaces and Times in Asia’, for which this paper was originally written. I greatly benefitted from all of the feedback I received at this workshop, and particularly from Prathama Banjeree, the discussant. Another earlier version of this paper was also presented at the workshop ‘Vulnerability and the Politics of Care’, and I would like to thank all of the participants for being excellent interlocutors. Finally, I would like to thank the anonymous reviewers and editorial staff of MAT, for their close reading, suggestions, and encouragement. 

About the author

Jason Danely is Senior Lecturer of Anthropology at Oxford Brookes University. He is author of Aging and Loss: Mourning and Maturity in Contemporary Japan (2014, Rutgers University Press), and co-editor of Transitions and Transformations: Cultural Perspectives on Aging and the Life Course (2013, Berghahn). He is President Elect of the Association of Anthropology, Gerontology, and the Life Course (AAGE). Jason is currently conducting cross-cultural research on the lived experiences of family caregivers of older adults in Japan and the UK, which is supported by the John Templeton Foundation Enhancing Life Project.

References

Allison, Anne. 1994. Nightwork: Sexuality, Pleasure, and Corporate Masculinity in a Tokyo Hostess Club. Chicago: University of Chicago Press.          http://dx.doi.org/10.7208/chicago/9780226014883.001.0001
Allison, Anne. 2013. Precarious Japan. Durham, NC: Duke University Press. http://dx.doi.org/10.1215/9780822377245.
Altez-Albela, Fleurdeliz R. 2011. ‘The Body and Transcendence in Emmanuel Levinas’ Phenomenological Ethics’. KRITIKE: An Online Journal of Philosophy 5, no. 1: 36–50. http://www.kritike.org/volume-5-1.html.
Arendt, Hannah. 1958. The Human Condition. Chicago: University of Chicago Press. 
Becker, Gaylene. 1997. Disrupted Lives: How People Create Meaning in a Chaotic World. Berkeley: University of California Press.
Brijnath, Bianca. 2014. Unforgotten: Love and the Culture of Dementia Care in India. New York: Berghahn Books.
Broadbent, Kaye. 2014. ‘“I’d Rather Work in a Supermarket”: Privatization of Home Care Work in Japan’. Work, Employment & Society 28, no. 5: 702–18. 
 http://dx.doi.org/10.1177/0950017013500113.
Brodwin, Paul. 2013. Everyday Ethics: Voices from the Front Line of Community Psychiatry. Berkeley: University of California Press.
Buch, Elana D. 2013. ‘Senses of Care: Embodying Inequality and Sustaining Personhood in the Home Care of Older Adults in Chicago’. American Ethnologist 40, no. 4: 637–50. http://dx.doi.org/10.1111/amet.12044.
Buch, Elana D. 2014. ‘Troubling Gifts of Care: Vulnerable Persons and Threatening Exchanges in Chicago’s Home Care Industry’. Medical Anthropology Quarterly 28, no. 4: 599–615.
Butler, Judith. 2004. Precarious Life: The Powers of Mourning and Violence. London: Verso Books.
Das, Veena. 2006. Life and Words: Violence and the Descent into the Ordinary. Berkeley: University of California Press.
Das, Veena, and Clara Han, eds. 2015. Living and Dying in the Contemporary World: A Compendium. Berkeley: University of California Press.
Edmonds, Alexander. 2014. ‘Surgery-for-Life: Aging, Sexual Fitness and Self-Management in Brazil’. Anthropology & Aging 34, no. 4: 246–59. http://dx.doi.org/10.5195/aa.2014.3.
Hardt, Michael, and Antonio Negri. 2001. Empire. Cambridge, MA: Harvard University Press.
Hromadžić, Azra. 2015. ‘“Where Were They until Now?” Aging, Care and Abandonment in a Bosnian Town’. Etnološka Tribina 45, no. 38: 3–57. http://dx.doi.org/10.15378/1848-9540.2015.38.01.
Ingold, Tim. 2011. Being Alive: Essays on Movement, Knowledge and Description. London: Routledge. http://dx.doi.org/10.4324/9780203818336.
Jackson, Michael. 2002. The Politics of Storytelling: Violence, Transgression, and Intersubjectivity. Copenhagen and Portland, OR: Museum Tusculanum Press.
Kaigo Rōdō Antei Sentā. 2015. Heisei 26 Nendo ‘Kaigo Rōdō Jittai Chōsa’ no Kekka [2014 state of care labor survey results]. Kaigo Center, 7 August. http://www.kaigo-center.or.jp/report/pdf/h26_chousa_kekka.pdf.
Kavedžija, Iza. 2015. ‘Frail, Independent, Involved? Care and the Category of the Elderly in Japan’. Anthropology & Aging 36, no. 1: 62–81. http://dx.doi.org/10.5195/aa.2015.83.
Koch, Gabriele. 2014. ‘Empowerment as Care: The Politics of NGO Intervention in Tokyo’s Sex Industry’. Paper presented at the American Anthropological Association meeting, Washington, DC, 3 December.
Kulick, Don and Jens Rydström. 2015. Loneliness and Its Opposite: Disability and the Ethics of Engagement. London: Duke University Press. http://dx.doi.org/10.1215/9780822375845.
Lambek, Michael. 2010. ‘Toward an Ethics of the Act’. In Ordinary Ethics: Anthropology Language, and Action, edited by Michael Lambek, 39–63. New York: Fordham University Press.
Larkin, Brian. 2013. ‘The Politics and Poetics of Infrastructure’. Annual Review of Anthropology 42: 327–43. http://dx.doi.org/10.1146/annurev-anthro-092412-155522.
Lynch, Caitrin. 2013. ‘Membership and Mattering: Agency and Work in a New England Factory’. In Transitions and Transformations: Cultural Perspectives on Aging and the Life Course, edited by Caitrin Lynch and Jason Danely, 188–205. New York: Berghahn Books.
Massumi, Brian. 2002. Parables of the Virtual. Durham, NC: Duke University Press. http://dx.doi.org/10.1215/9780822383574.
Mattingly, Cheryl. 2014. Moral Laboratories: Family Peril and the Struggle for a Good Life. Berkeley: University of California Press. http://dx.doi.org/10.1525/california/9780520281196.001.0001.
Mazus, Keren. 2013. ‘The Familial Dyad between Aged Patients and Filipina Caregivers in Israel: Eldercare, Bodily-Based Practices, and the Jewish Family’. Anthropology & Aging 34, no. 3: 126–34. http://dx.doi.org/10.5195/aa.2013.13.
MHLW (Ministry of Health, Labour, and Welfare). 2012. ‘Kaigo Shokuin wo Meguru Genjō to Jinzai no Kakuho no Taisaku ni Tsuite’ [On the security of the labour force and status of care workers]. 22nd Year of Heisei Nursing Service Facilities and Offices Survey. Ministry of Health, Labour, and Welfare, 2nd Social Security Council Welfare Committee, Welfare Human Resources Expert Committee Documents. http://www.mhlw.go.jp/stf/shingi/2r9852000002ae5j-att/2r9852000002aej7.pdf.
MHLW. 2015. ‘Heisei 25 nendo Kōreisha Gyakutai Taiō Jōkyō Chōsa Kekka Gaiyō’ [Results of the survey of elder abuse problems]. Ministry of Health, Labour, and Welfare. http://www.mhlw.go.jp/file/04-Houdouhappyou-12304500-Roukenkyoku-Ninchishougyakutaiboushitaisakusuishinshitsu/0000073579.pdf.
Miyoshi, Haruki, and Serizawa Shunsuke. 2003. Eldercare and Eros: The Connection between Childcare and Nursing Care [Rōjin Kaigo to Erosu: Kosodate to Kea wo Tsūtei Suru Mono]. Tokyo: Kirara Shobō.
Mol, Annemarie. 2008. The Logic of Care: Health and the Problem of Patient Choice. New York: Routledge. http://dx.doi.org/10.4324/9780203927076.
Moore, Katrina. 2010. ‘Sexuality and Sense of Self in Later Life: Japanese Men’s and Women’s Reflections on Sex and Aging’. The Journal of Cross-Cultural Gerontology 25, no. 2: 149–63. http://dx.doi.org/10.1007/s10823-010-9115-9.
Muehlebach, Andrea. 2011. ‘On Affective Labor in Post-Fordist Italy’. Cultural Anthropology 26, no. 1: 59–82. http://dx.doi.org/10.1111/j.1548-1360.2010.01080.x.
Muramatsu, Naoko, and Hiroko Akiyama. 2011. ‘Japan: Super-Aging Society Preparing for the Future’. The Gerontologist 51, no. 4: 425–32. http://dx.doi.org/10.1093/geront/gnr067.
Nakamura, Karen. 2014. ‘Barrier-Free Brothels: Sex Volunteers, Prostitutes, and People with Disabilities’. In Capturing Contemporary Japan: Differentiation and Uncertainty, edited by Satsuki Kawano, Glenda S. Roberts, and Susan Orpett Long, 202–20. Honolulu: University of Hawai’i Press.
Nortvedt, Per. 2003. ‘Subjectivity and Vulnerability: Reflections on the Foundation of Ethical Sensibility’. Nursing Philosophy 4, no. 3: 222–30. http://dx.doi.org/10.1046/j.1466-769X.2003.00120.x.
Nussbaum, Martha. 1986. The Fragility of Goodness: Luck and Ethics in Greek Tragedy and Philosophy. Cambridge: Cambridge University Press.
Obeyesekere, Gananath. 1990. The Work of Culture: Symbolic Transformation in Psychoanalysis and Anthropology. Chicago: University of Chicago Press.
Parish, Steven. 2008. Suffering and Subjectivity in American Culture: Possible Selves. New York: Palgrave MacMillan. http://dx.doi.org/10.1057/9780230613188.
Pinchevski, Amit. 2012. ‘Emmanuel Levinas: Contact and Interruption’. In Philosophical Profiles in the Theory of Communication, edited by Jason Hannan, John Durham Peters, and Richard Bernstein, 343–66. Vienna: Peter Lang International Academic Publishers. http://dx.doi.org/10.3726/978-1-4539-0202-8/18.
Povinelli, Elizabeth A. 2011. Economies of Abandonment: Social Belonging and Endurance in Late Liberalism. Durham, NC: Duke University Press Books. http://dx.doi.org/10.1215/9780822394570.
Rapport, Nigel. 2003. I Am Dynamite: An Alternative Anthropology of Power. London: Routledge. http://dx.doi.org/10.4324/9780203634318.
Rapport, Nigel. 2007. ‘On Well-Being, Being Well and Well-Becoming: On the Move with Hospital Porters’. In Culture and Well-Being: Anthropological Approaches to Freedom and Political Ethics, edited by Alberto Corsín Jiménez, 95–112. Ann Arbor, MI: Pluto Press.
Rapport, Nigel. 2015. ‘Anthropology through Levinas: Knowing the Uniqueness of Ego and the Mystery of Otherness’. Current Anthropology 56, no. 2: 256–76. http://dx.doi.org/10.1086/680433.
Sankei West. 2016. ‘Hōmon Kangoshi no 5 wari “Riyōsha, Kazoku kara Bōryoku Uketa” Sekuhara Higai mo Kōbe-shi Kango-Dai Chōsa’ [Fifty percent of home visiting nurses: ‘I have been abused by a care recipient or family’; also sexual harassment victims. Kobe City Nursing College Survey]. Sankei.com, 18 June. http://www.sankei.com/west/news/160618/wst1606180055-n1.html.   
Stacey, Clare L. 2011. The Caring Self: The Work Experiences of Home Care Aides. Ithaca, NY: ILR Press.
Stevenson, Lisa. 2014. Life beside Itself: Imagining Care in the Canadian Arctic. Berkeley: University of California Press.
Stewart, Kathleen. 2007. Ordinary Affects. Durham, NC: Duke University Press. http://dx.doi.org/10.1215/9780822390404.
Suzuki, Shin. 2015. ‘Kaigo Shokuin no Jinzai Ikusei no Genjō to Kadai’ [The issues and status of developing the professional care workforce]. Kea Zine, 14 January. Accessed 21 August  2016.  http://www.caretomo.com/carezine/article/41/190/article.html.
Twigg, Julia. 2000. Bathing: The Body and Community Care. London: Routledge. http://dx.doi.org/10.4324/9780203190876.
Twigg, Julia, Carol Wolkowitz, Rachel Lara Cohen, and Sarah Nettleton. 2011. ‘Conceptualising Body Work in Health and Social Care’. Sociology of Health & Illness 33, no. 2: 171–88. http://dx.doi.org/10.1111/j.1467-9566.2010.01323.x.
Whitelaw, Gavin H. 2014. ‘Shelf Lives and Labors of Loss: Food, Livelihoods, and Japan’s Convenience Stores’. In Capturing Contemporary Japan: Differentiation and Uncertainty, edited by Satsuki Kawano, Glenda S. Roberts, and Susan Orpett Long, 135–60. Honolulu: University of Hawai’i Press.