An anthropological writing (April 14th, 2023) by Tongtong (Petra) Yang for the course, Anthro 216GH: Case Studies in Global Health
Caregiving in community-based systems has been practiced in global health for its effect in transforming local systems of disconnected community and healthcare. This paper will compare the caregiving and community health in Boston, MA, USA and Okayama city, Japan, and use these comparisons to discuss the implications and actionable insights.
Individual caregiving responsibilities and Organization operational structure
In Okayama city, Japan, Hiroko and Toshio Kashiwagi have multiple responsibilities as community care workers. They utilize their professional experience and knowledge about caretaking to serve their clients, the elderly and the disabled, train new care workers, and together run an NGO that offers community in-home help and affordable transportation services. The NGO sends home helpers to the clients to help with their daily routines, keeps an eye on their health condition, and contacts medical professionals if needed. The clients always have health concerns due to aging or disabilities. Toshio, using his knowledge as a retired special school principal, offers taxi transportation in a four-wheel welfare vehicle for clients to travel from their homes to nursing homes, hospitals, parks, stores, welfare facilities, and conveyor belt sushi restaurant. He also accompanies the clients throughout shopping and medical checks. Hiroko, as a professional caretaker, cooks for the clients, sweeps the home floor, does laundry, asks how the recent medical check went and whether the client took the medicine that day, and sometimes promotes the client to stop smoking because it is bad for their health. Although this NGO offers community in-home help, not community healthcare for the “indigent HIV-positive” patients like that of the Prevention and Access to Care and Treatment project (PACT) in Boston, MA, USA; individual caregivers’ responsibilities are similar and both act as the bridge between clients and doctors, except for the domestic housekeeping and welfare transportation parts. Working as either health promoter (HP) or directly observed therapy (DOT) specialist, community health workers (CHWs) in PACT visit patients’ homes regularly to talk about health, specifically on topics of HIV, the patients’ “health behaviors,” and social services available to them; they also help the patients learn about their medications and make sure they take the meds. CHWs do not help with housekeeping or transportation.
On the organizational level, PACT has a more role-specific operational framework. With PACT, CHWs practice community health caregiving and receive continuous training in medical science by the training and technical assistance team. The HIV program manager monitors CHWs and contacts patients on formal inquiries. The clinical supervisor makes sure CHWs are well, takes in patients, and outreaches the doctors locally. The accounts manager and administrative coordinator takes care of PACT’s financial situation and administrative work. The executive director and the director of operations supervise all. In Okayama city, however, Hiroko and Toshio perform multiple roles. Apart from caregiving and home helping, Hiroko works on the finance and administrative arm, also contacts local agencies and manages the NGO. Toshio offers more than welfare transportation. He connects with new welfare taxi drivers and trains them.
Both the NGO and PACT function well. Although the roles are mixed or more concentrated, the caregivers offer actionable insights for community caregiving:
– going into clients’ homes
– performing their responsibilities fluently and understanding the group they serve (knowledge in HIV, aging, and disability)
– build relationships with clients, doctors, and more.
What is community?
In PACT, community is a metaphor of belonging; it is beyond physical space. Community takes the forms of understanding between CHWs and patients through shared experiences, as space and place of the clients, and as the relationships between CHWs and the patients. In Okayama city, the community takes similar shapes. It happens in the relationships between doctors, caregivers of the NGO (which literally translates as support group having tea together, 共助团体吃茶去), clients, and their families. It happens in clients’ homes, the NGO office, the hospital, and other places the clients and Toshio reach and explore together using the NGO’s welfare taxi. Both PACT and the NGO address the clinic-community gap by regularly visiting the clients’ homes and accompanying them, and the NGO goes further to offer convenient transportation for the clients.
Insights for community caregiving:
- Share experiences with clients
- Respect and encourage clients’ space
- Accompany the clients and regularly visit them at home
Social and political economies
How has the community health workers and caregivers understand the impact of social and political economic forces on clients’ health and living? The Kashiwaga couple understand that these forces set roadblocks and created many rules for welfare transportation and in-home helping services because the government cut the budget and support. What the clients pay barely covers the cost like parking and gas. Toshio becomes a volunteer driver for the welfare not-free transportation. Hiroko says the NGO faces a financial crisis. Before 2006, the elderly and disabled could travel using the free extra service of home services companies. The normal taxi drivers claimed that these services influenced their business and campaigned against these free services, thus came the slightly-paid, almost-volunteer welfare taxi drivers. The drivers need to make sure they do not conflict with the taxi industry to become volunteers. Toshio had to purchase this welfare vehicle using his pension. Before PACT, the primary and rural community health field has a long history of various policies in different times and needs. PACT bases its framework on Partners in Health (PIH)’s Haiti work and has been training and supporting new health workers with its model.
Insights for community caregiving:
- Research and understand the impacts of previous practices and current local and national policies about community health and caregiving
- Communicate with other organizations offering care, provide training
- Be prepared for advocating for more support and taking risks as caregivers
Through what lens did the observation happen?
In his project on PACT, Mei acted as an “inquisitive observer,” observing different situations and listening carefully to understand “what it means for CHWs to work in the community and give care” and the local moral worlds (Kleimann 2006) through the interactions between stakeholders. Soda is also an observer. His documentary style is innovative observational. Using his camera, he observed the Kashiwagi couple and their clients’ work and life moments with least assumptions, has no scripts, previous planning, or theme, and uses least music, subtitles, and prologue, to encourage the audience to actively observe. Soda self-funded his films to stay independent of bias the funders would bring to the table.
Bibliography
Soda, K. (Producer & Director). (2010). Peace [Motion picture]. Japan: Laboratory X, Inc.
Soda, K. (2023). Why I Make Documentaries. On Observational Filmmaking (S. Grasselli, Ed., M. Schley, Trans.). Viaindustriae publishing. (Original work published 2011)
John (Yuynag) Mei, 2012. “Caregiving Among Community Health Workers in Boston: The PACT Model.” Undergraduate thesis, Anthropology, Harvard College.