Care and Kara

It started blandly enough, me looking for Ida in a snowy Chicago alley. Then the boy appeared. He was striding fast as if trying to catch up. But I didn't know him. Then two others appeared from a building in front of me.At first I thought, They're meeting each other. But the angles were off, hands in pockets, everyone wearing the same colors.At least one agency in town was providing guards for visiting nurses at the time, but not for the likes of me, a mere CNA (certified nursing assistant). I'd been mugged before in my life, once in San Francisco, twice in Chicago, so I thought I knew what I was looking at. A gang initiation would probably have been one guy, I thought; a rape would probably not be a late-afternoon attack in a salty slippery alley.On the other hand, what did I really know?Drop my backpack? Toss them the car keys? The boys were speeding up. I couldn't run in the slush, my phone was somewhere in my backpack, my car was behind me.And then Ida screamed.She was standing fifteen yards away and waving her arms, swerving, and shouting, shouting, shouting.The two boys paused, reversed course, heads down. The anchorman slid past me to join the other two, Ida still shouting. Then they all sauntered by her, and one of them said something she wouldn't repeat.She was breathing hard when I got to her.I was mortified. But she laughed. “Bad enough to have cancer, but girl, you almost gave me a heart attack. I thought I told you the other corner.”Of course she had. “I'm so sorry.”I opened the car door. She heaved herself in, still laughing her relief. I laughed along, and soon I would be changed, by Ida, and by a thing we shared: kara.I'd come to care work as a former tech leader with a three-page résumé and no particular experience in giving care or getting it. When I was 10 and told my mother than I wanted to be a nun or a gym teacher or a nurse, she had one response. “Nursing,” she sneered. “Bedpans.” I had no idea what a bedpan was, but I knew I was never going to be a nurse.If you'd asked her about care, what it was, why it wasn't something she valued or practiced or even thought about, she'd have shrugged. She was a woman of low-calorie lunches and manicured hands, educated but not introspective. Later, as she descended into helplessness and fought all help, she made it clear that in her mind care was humiliation. She was aided by my father, who saw care as an invasion of privacy. He believed himself to be a man who'd used his bootstraps well.Neither of them would have been happy to see me driving Ida to the laundromat, unloading the car, and loading and unloading the washers and then the dryers. Weeks of laundry, sheets, winter coats, and blankets dragged in my arms.I could hear my mother. “We sent you to Stanford for this?”Care is a noun, a verb, a service, a feeling, a value, an action with roots in the Proto-Germanic kara, meaning lament or grief. I find that telling. There's a metaphorical weight in care. It's a sad word. It contains burden. “The sorrow-clouded breast of Care,” Samuel Coleridge wrote.Also telling: Its positive permutation, to have regard for, seems to have emerged as a negative, as in “I care not . . . ” and “He never car'd much . . . ” That's probably why even now care is not love. “I care for you” isn't “I love you passionately and will love you forever, even after you dump me for the guy with the Lamborghini.” I care for you has a remove in it; it is more concern than ardor. It's the word the girl reaches for as she tells you that she likes you but she's just taken a job on a remote island off the coast of Greenland and has no plans to see you ever again. It is a word that demands an adverb to give it a bump of emotional intensity as in “I care . . . deeply,” and even then, you know the girl is not talking euphoria. That troublesome root—kara—haunts it.Or distinguishes it. Now, pulling down the wrecked road in a neighborhood I would never dare walk through, this is what I was beginning to see: Kara is crucial. Kara—burden—makes care a value higher than love. Falling into euphoria, with stars in your eyes and plans for a destination wedding, is easy. Care is harder: It's freighted with challenge. If there isn't challenge, then the thing you're doing is love, it's kindness, it's a gesture. It's worthwhile, but it's not care.Care is cumbersome. It's sustained. When a woman falls on the sidewalk, you can walk by or help her up. Helping her up is a kindness. But then it swerves into care. You discover she's been mugged, so you stay with her until the police arrive and miss your job interview. Care is inconvenient. Kara makes it that way.I'll go further. Kara is what makes it difficult—maybe impossible—for capitalism to do care well. After all, each patient's illness and each child's ache is idiosyncratic; each death has its own arc. There's comorbidity. The kid with strep turns out to be unhoused. The man's greatest fear—the thing that's wrecking his sleep—is a disease he doesn't have. How do you commodify my mother's hallucinations, my father's congestive heart, Ida's tumors for profit? How do you make caregiving a market-ready product so that tending to their individual and shifting needs is akin to serving a Diet Coke?You try to do it by breaking each effort down into discreet pieces—tasks that can be categorized, contained, and given a market value. Oddly, I learned this from the founder of McDonald's. Long ago, I shepherded research for a museum about Ray Kroc. I read his letters. I interviewed his early lieutenants. I even met with Dick McDonald, one of the brothers who had invented the Speedee Service System that made Kroc go weak in the knees back in 1954. Speedee was a riff on Henry Ford's assembly line, where each worker executed, over and over, just one of the 84 simplified tasks it took to make a car; Kroc saw that the McDonald brothers had done the same thing with burgers, and he could package and franchise their method. This way, no one cooking a french fry or wrapping a burger could stray or innovate or cost more than budgeted; this way, a burger made in Dallas was the same burger made in Denver, and profits would be sizable and predictable.Under capitalism, private health insurers use the same recipe. They classify health conditions and apply monetary value to their discreet, prescribed treatments. This leverages Western medicine's Cartesian framework, which essentially sees bodies as machines, and illnesses as mechanical glitches. Parts are parts. Methods are methods. Codes are attached. So treating a man with atherosclerotic heart disease with angina pectoris (I25–7) accompanied by the presence of aortocoronary bypass graft (Z95.1) in New Orleans should be the same as treating one in New Jersey, and costs should be similar.It's true, heart attacks share features. But hearts aren't hamburgers. They're embedded in human bodies; they're in conversation with human lives, which are variable, and kara often lives in those variations. When my father was prematurely discharged after quintuple bypass surgery deep in the bowels of the New Jersey Pine Barrens, my sister loaded him into a rental car and drove two hours north, as my mother chattered hallucinatory thoughts in the seat beside her. Kara. Left in my care that night, my mother would pummel her husband of 63 years in his surgical wound; he'd defend himself and hit her, and she'd fall on her back, uncomprehending. Also unremembering: Who was this middle-aged woman, kneeling beside her now, calling her “Mom”? My father was writhing in new pain. Kara. I gave him meds. Then I picked my mom up, and then I stayed up, all night for two nights, guarding. Kara.Classification had worked for my father's diagnosis, and it has for most of my clients. Classification also prompts effective treatment much of the time, particularly if the patient fits the ethnic, socioeconomic, and gender categories that have traditionally dominated medical research. Even medical researchers who decry the mechanistic ethos of Western medicine embrace classification. They do worry that classification makes it easy for clinicians to coast along, fixing human parts as if they were brake pads in what the philosopher Martin Buber called I-it relationships: I, the doctor, see you as It, a machine with a codified problem. Instead, some have proposed an alternative model that draws on Buber's I-thou construct. In I-thou, the I is fully present, fully open to the living realities of the thou. Both the I, the doctor, and the thou, the patient, influence how treatment unfolds . That said, even among these thinkers, classification in diagnosis and treatment remains sacrosanct. How else would practitioners identify and treat pathologies across time or continents?But care—that's where classification fails. Care is variable, relational, multilevel; care depends on Buber's I-thou. A homecare colleague calms our client by singing her favorite song from the 1950s. A clerk waits for me outside a closed CVS with meds my client desperately needs. My father's visiting nurse brings me out to the driveway. Inside, my mother is napping and my father is fretting. “Your parents can't ever live together again,” the nurse says. She'll persuade a doctor to prescribe a rehab facility for my father, so he can be safe. “But your mother—”“I know.”“Here's my personal phone number. I'm not supposed to do this. But if you need me, call.”Capitalism can't do those things and make sizable and predictable profits. It must ignore the thou and negate the kara. It must minimize differences between a heart patient with a healthy wife and a heart patient with a dangerous one; it must undervalue the work, it must serve burgers. It dodges human circumstances; and in the dodging, leaves real care to family, community, underpaid workers.That's why you find grief etched on my sister's face and mine.In the car, Ida talked about her pain. The radiation treatments were worse than the disease, she said. The fatigue felt like liquid; her skin felt like fire.“I didn't know radiation hurt.”“Yeah. You'd think I would have known,” she said. She was a homecare worker, too, she explained. For the last two years, she'd been caring for a husband and wife who both had cancer. But she'd had to quit because of her illness.I couldn't picture it. The three of them in a house together, wounded and trying to heal. I pulled into the laundromat.It would be years until I read the work of the political philosopher Daniel Engster, and the three of them in that house began to make some sense. For Engster, the I-thou ethic may be real and useful. But it's also evanescent and limited. He asks: How can a society build caring institutions? How does caring happen in the absence of an I-thou dyad—for certainly it does? Is something else, something social, operating here? He finds answers in human history. Care is both social and organic, he says. It's core to human evolution.His thinking goes like this. Because human beings are born dependent on care—feeding, holding, teaching, protecting—care is the primary human ethic. Care—not love—is the thing that binds and builds families, that drove the ancient invention of human communities as Homo sapiens came to realize that mutual care could make hunting and gathering easier and roads and schools possible. Care is the concern that fights forest fires. Care believes in fairness, so it espouses justice, as protection for all. Care provides safety, promotes survival. Without care: no functioning families, no thriving tribes, no schools, no justice, no next generation. It is the very center of human morality.Without it, the species simply doesn't make it.So maybe something organic happened in that house, with Ida and her clients. With their purposes merged—survival—a natural process formed. They found strength and healing in each other's mortal struggle. “They were more than clients,” she told me. “I'm going to miss them.” And surely, they would miss her.In the laundry, Ida announced she was going food shopping and started for the door. She took a step, leaned against a washer. Two steps, pause. Three steps, pause.“Hey Ida, Why don't I drive you?”Now she sounded like my mother: “You're going to drive me across the street?”“Okay, okay. Go splat if you want to.”“I plan to.”When I reported this to my mentor Joan a few days later, she gasped, which was not advisable, as she had COPD. “You'd never get away with saying that in a hospital,” she coughed.“True. But she'd already made fun of me for my bad sense of direction.”“Right.” Joan was a retired nurse from the clipboard generation, fitted dresses, dismissive doctors, paltry pay. She'd staffed a maternity ward, and later ran support groups for cancer patients. She was living on Social Security, $1,200 a month. I'd met her years before, as my first pro bono client. We'd spent hours fixing her computer, fighting with Comcast, figuring out which bills she could afford to pay—and in the emergency too, where she in for a night, as I out a nurse, a doctor, and a In Joan she is what you're I your husband think about My husband was of me. for a After all, he an not a he didn't want to know I was their kneeling to their he valued care. a social worker, he'd worked on the as a he for death with and he didn't like was the of care I was In providing care, I'd a social to join a a by and a of a of where the were and maybe even How could I to be one of wasn't in his I didn't go a some of about my why are you doing must be up for not is You know it's about time you got over your is doing this because of your “You're not to this. from do this you like you're hard to your to do care, when the you think you're your And it's hard to about those So I didn't Joan when she asked about my at me eyes by She said, a took and we on to about the kara in the She She She me about the and the the of bodies and and also the holding, when the A she wanted to be A woman in the last days of her as her it like the work because it's I said, I'm at Joan said. She and Ida were probably the who would me on that The very thing that capitalism me, called me to to new of in the of the is me, doing the his his for her when she about the him before his the about the in my back that between and catch the her all the that I can't see and that Why are you I I can do that And her into her first in with of a and up in her She got her. the of her But she doesn't why know there are in this town who would a for this of I and she the first time they don't know about I something was a human meaning Buber the meaning lives in the I-thou. But I also and Joan that much of the meaning draws from the of kara, the of it and its to the kara is my an of the kara is which I what so of out of the of care. You'd think the do it. the the I know the of grief is to who are for and is and it is that one I three But I have to It's what do to the of care that makes care 10 years, of what I did for pro bono was He was a who'd spent much of his later years about guy with heart and no For I fought his building over something they were by to A of him. as he from his I in a nursing as the nurse with an over the they were as to we should have on how to surgical Both knew how to the they were should have done the nursing nurse should know enough to do that one the was the of the in I'd out and a into his and I'd his in a I'd him I was and “I don't know what to I got a nurse in the me. she said, and down the to She quit soon Dick called me from the nursing and said, been his for an as his the time I the night phone some heart was nurse had to care I knew favorite who was not that night, had the told about her how she couldn't get help to how were by who in the all how favorite social worker had been for visiting with the of that of course, the the laundry, Ida are you was for an agency was, This is because up homecare by as much as and don't like was, clients. If you work for them we will come after But Ida and I were in the work, so I told her what I was And she told me she'd been more for can have my she agency was a from a with and A woman with a of behind a in and out The in the She a a with a guy from a Ida made it to the picked up her last and to me. really she said. The woman to a the she said. But the was Ida to get back to the but couldn't get the I Ida was should come back Then she called my agency and me, and I called and asked to be to her, but my agency So I never saw Ida again. She Chicago because her didn't the care she and she had a in never back to her agency or even to I That way, the kara make more think of her She was to have that I him the I'd down the from her to his car, and in his Kara. He pulled out and drove the was Ida was a She the she never asked why I was didn't think it was that I was or came from who to a she saw the thou or maybe she felt a human In she I would go and as a of course, she made it so by caring for me that would work in care for 10 years, the kara and also because of it. My husband would come to the work and support it. He would me when I and much later, He would as I his and told to and his meds. the we Ray together, a with from the to the not a bad it is a human It And much of the time it course it's It's for an for a But an from the and and from a with Ida, and a with Kara is a of and it can be and and in the something is care and a species that its next generation.