Mara de la Luz Ibarra

Department of Chicana and Chicano Studies

San Diego State University

Frontline Activists: Mexicana Care Workers,

Subjectivity, and the Defense of the Elderly
In this article, I focus on Mexican immigrant women who, as care workers in
various care settings in the wealthy city of Santa Barbara, California, attempt to
defend aging Americans patients from devaluation and harm. To understand why
vulnerable women defend more privileged citizens of the nation, I address Mexicana
subjectivity. I argue that neoliberal policies have created multiple vulnerabilities for
Mexican women and it is in formal care contexts where these vulnerabilities intertwine with that of their patients. Workers feelings of shame, complicity, and
empathy help explain a defense of the Other. A significant form of defense is informal sector family-based care. This article is based on ethnographic fieldwork
conducted between 2009 and 2011. [southern California, care work, immigrant
women, subjectivity, informal economy]

Introduction
While conducting research on job practices and conditions among Mexican immigrant women employed as elder care providers in Santa Barbara, California, I have
been repeatedly struck by these womens expressed concern about the plight of aging people in the city. Yes, they talk about their low wages, their long hours, and
their tired bodies. They also talk about other critical social issuesthe daily fears
associated with living in a society where lack of documentation can lead to deportation or of what might happen to them, and consequently their families, should they
get injured and not be able to perform their jobs. In Santa Barbara, commoditized
elder care, without a doubt, takes its toll. But over and over, some of the strongest
words and sentiments expressed by women are associated with the condition of the
Other. These words include: abandoned, alone, thrown away, coldness,
and desprecio (devaluation).
Mexicanas also speak of defending their aging patients, often at a great personal cost. This is, in a sense, a world turned inside out: Neoliberal policies have
shaped the migration of Third World women into the First, reproducing longstanding global power inequalities as more privileged First World subjects mine their
labors. Yet these Mexicanasoften without legal standing, outside the realm of
political culture and societynot only question the logic of this social reality, but
MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 27, Issue 3, pp. 434452, ISSN 0745C 2013 by the American Anthropological Association. All rights
5194, online ISSN 1548-1387. 
reserved. DOI: 10.1111/maq.12051

434

Frontline Activists: Mexicana Care Workers

435

through specific deeds attempt to change its character for the good of others. What is
the basis for such actions? How do we understand such seemingly incongruous acts?
Anthropologists and other social scientists have documented the rise of a new
economic model of care in which what is just and what is profitable do not necessarily coincide (Rylko-Bauer and Farmer 2002). Nurses and caregivers, too, in
different institutional care settings, have stood up for what they believe is just
both for themselves and for their patients (Gordon 2005; Wengler 2003). Rejecting
a standardized model, caregivers are at the forefront of a struggle to humanize care.
But in this literature, the focus is solely on the regulated care sector, to the exclusion
of the unregulated informal sector where many immigrant women labor.
Here, I focus on Mexican immigrant women who have intentionally left the
formal elder care sector for the informal. To understand this move and the particular
type of care that Mexicanas create, I address womens subjectivity (i.e., their inner
life processes and affective states [Biehl et al. 2007:5]) as migrant workers. I
argue that in a southern California city such as Santa Barbara, neoliberal policies
have created multiple vulnerabilities for Mexican women, and it is in local care
contexts where these vulnerabilities intertwine with those of their patients. Here,
frontline workers profound feelings of empathy, complicity, and shame help explain
a defense of the Other, a defense that points to new possibilities. One especially
significant example of defense is workers creation of alternative family-group care
arrangements that stand in contrast to what women see as wrong in the citys formal
care landscape. These actions are a refutation of the existing normalization of bare
minimum care and an assertion of different values and a different model where there
is time for love, intimacy, and dignity for patients and themselves.

Neoliberalism, Labor Activism, and Care Workers

Over the last three decades, globalization has heralded the collapse of the modern
industrial order and the rise of a neoliberal brave new world of deregulated markets and diminishing state engagement with social welfare (Harvey 2005). In this
era, scholars concerned with the effects of restructured workplaces have focused
on worker agencyactions taken by socioculturally constrained workers to effect
change (Ahearn 2001; Giddens 1993; Ortner 1997) on conditions and logics imposed by corporations (Lichtenstein 2003; Ong 1987). Agency is not reducible to
empowerment nor is it all transforming (Gunewardena and Kingsolver 2007), and
it manifests itself in different forms. These forms include overt practices as well
as more nuanced expressions that include everyday forms of resistance (Scott
1985:xvi) not typically in the public eye. Both types of agency, in turn, may constitute activismhere defined as the struggle against the drive to normalization . . .
and the commitment to the cultivation of those dreams and practices that strive to
produce newer forms of human possibility (Dave 2011:3).
Among care providers whose work requires close, personal contact that is motivated partially by a concern for the welfare of the other (Folbre 2001:6), activism
has involved collective action against the new normal. Formal sector caregivers, in
particular, have fought for a social wage (Boris and Klein 2012) and the well-being
of their patients. For example, nurses have criticized how restructured institutions
which promote standardization, cost cutting, and corporate profitnegatively affect

436

Medical Anthropology Quarterly

patients. They have challenged hospital administrators who compromise on staffing,

supplies, and quality, and they have struggled to retain patient-centered care in the
face of a profit-centered imperative (Gordon 2005; Wengler 2003). Activism for
these workers stems from a critique of the new care model, but it also invokes
something better: a profession where nurses and aides can attend to individual
patients based on their specific needs.1
Not all worker activism against rationalized care takes place in public or in collective protest, of course. Some workers engage in everyday resistance, individually
refusing to act in prescribed ways or dragging their heels to hold up the actions
of a disputed process. In various nursing homes, aides and nurses, for example,
ignore or defy rules imposed from above (Diamond 1992; Foner 1995)sometimes
to avoid work (McLean 2007)but also to prevent unnecessary suffering to their
patient (Hov 2009). In these settings, particularly where life and death are in the
balance, moral certainty may inspire some workers to stand up or speak out
(Oberle and Hughes 2001). Activism in these cases directly supports patients as well
as alleviates nurses feelings of professional irresponsibility (Hov 2009).
Activism in the formal sector care also includes private caregivers. In California,
an important source of employment is the state-funded In Home Supportive Services
(IHSS) program, which goes by different names in other states and employs large
numbers of immigrants. These low-paid state workers have been at the forefront
of union organizing (Boris and Klein 2012), and in 2011 they took to the streets
once again to protest threatened wage cuts. They did so to express concern with
the needs of their patients as well as themselves (Decasus 2011). For some aides,
in fact, good work conditions are central to the performance of good care (Stacey
2011), an idea that underscores the relational nature of the work. Internationally, the
demand for care has also led to programs in which Third World women are the livein servants of globalization for First World families (Constable 1997; Parrenas

2001). These workers are so ubiquitous that Arlie Hochschild evocatively compares
the extraction of their love to the colonial-era mining of gold from the Third World
(2003). Indeed, Evelyn Nakano Glenn argues that women of color are forced to
care within a system of gendered/racialized servitude (2012). These global workers
have also organized to protest their poor working conditions as well as inequalities
tied to race, citizenship, and gender in First World countries (Chin 1998).
Despite this rich literature, we know significantly less about informal elder care
workers, most of whom labor in private homes and are paid directly, in cash or in
trade, by employers. The informal economywhich consists of income-generating
activities not regulated by the statenonetheless constitutes a central feature of
contemporary post-industrial societies (Sassen 1988), often subsidizing formal activity. This sector has rapidly expanded since the 1980s, and women who work
as house cleaners (Romero 2002 [1992]) and care providers experience many serious problems (Degiuli 2007; Hondagneu-Sotelo 2001; Ibarra 2000). We know,
too, that to counteract negative conditions, some women engage in everyday forms
of resistance and sometimes in public actions. Much of this literature, however, is
primarily concerned with what women do and less so with the subjective feelings
that may propel action.
In sum, activism among care providers in the formal sector consists of worker
efforts to improve conditions for themselves and for patients, through both public

Frontline Activists: Mexicana Care Workers

437

and internal efforts. In so doing, workers critique the new model of care and invoke
something better. Studies of informal domestic workers demonstrate the increasing
importance of this type of employment in the First World as well as of workers
activism both in and out of the workplace. However, in these studies there is a
tendency to privilege what people do to the exclusion of what people feel and think.
There is a tendency to slight . . . the subject as existentially complex (Ortner
2004:41). A focus on immigrant women who care for elderly patients in a city with
a large aged population like Santa Barbara adds to this literature on care by focusing
both on what women do and the feelings that may help shape their activism.

Subjectivity: Social Experience and Feeling amid Instability

For millions of people, contemporary life under global capitalism is characterized
by conditions of economic crisis, displacement, and violence, which, in turn, shape
subjectivity. Some scholars have theorized that this condition of instability creates a very specific social and psychological effect: a corroded self tied to the
lack of long term sustained human relations and durable purposes (Sennett in
Ortner 2004:58). Other scholars, although acknowledging the impact of rapid
global change, nonetheless argue that what happens to the self under these conditions is not universal or self-evident (Kleinman and Fitz-Henry 2007).
Rather than conceptualizing one trend, it is more fruitful to address subjectivity as
dynamically formed and transformed (Biehl et al. 2007:10). Several characteristics
stand out. Power and power relations frame lives at various levelsfrom the nationstate that shapes the life chances of infants (Scheper-Hughes 1993) to local contexts
that shape the daily lives of poor people (Biehl 2005). Contemporary analysis of
subjectivity, likewise, involves addressing intersubjectivity. As Arthur Kleinman
notes, the subjective is always social, and the social subjective (2006:68). Subjective
experiences, moreover, are rooted in local moral worlds where certain values not
only matter but may, in fact, be most at stake (Kleinman 2006). Focusing on
what matters most to people in traumatic or rapidly transformed conditions helps
put certain imperatives into sharp relief (Kleinman 2006).
In the case of elder care, as in conditions of war and violence, what is often
most at stake is life itself. Recent ethnographies that take the imperative of preserving life have addressed why individuals become and remain involved in high-risk
social action. In Colombia, Winifred Tate argues that human rights activists who
have built their sense of self trying to preserve life find it difficult to walk away
without jeopardizing their moral identities and may even see persecution as normal
(2007:156160). Among some care workers, too, the performance of good care
provides the basis for a moral (Ibarra 2003) or caring self (Stacey 2011), an
identity that reinforces commitment to patients in spite of economic exploitation.
Preserving life is also emotionally rewarding. Colombian activists experience a
profoundly motivating emotional force (Tate 2007:148), while peasant insurgents
standing up to the state in El Salvador experience the pleasure of agency even
when victory is unlikely (Wood 2003:20). Just as importantly, some activists are
moved to preserve life because of remorse for actions previously taken or not taken
(Scheper-Hughes 2007). Thus, people not only feel an emotion but may also feel
compelled to act.

438

Medical Anthropology Quarterly

In what follows, I address how contemporary Mexican womens subjectivities as

immigrants and workers form the basis of activism on behalf of others in a society
where they themselves are vulnerable. Mexicanas in the neoliberal diaspora carry the
emotional weight of fear produced by economic dislocations and violence in their
home communities; they carry the loss of homes, family, friends, culture, and a way
of life; they bear the physical and emotional scars of clandestine border crossings
and the impossibility of return. These women come to the United States where
like other Third World women globallythey become the servants of globalization,
paid to care for others as an underground army of laborers (Chang 2000), remade
into illegal subjects (Ngai 2003).
Some of these women make their way to Santa Barbara.

Santa Barbara, Mexican Elder Care Workers, and Methods

Santa Barbara is located 85 miles north of Los Angeles on a narrow strip of coastal
plain between the Santa Ynez Mountains and the Pacific Ocean. It is a wealthy
city where Hollywood movie stars, corporate CEOs, and celebrity athletes mix
with the heirs of eastern industrial titans and international moguls. From its central
town grid to its winding hillside roads, the dominant architecture conforms to an
early 20th-century Spanish fantasy. The signs of privilege abound: gated estates,
polo fields, marinas, yacht and country clubs as well as hyper-fit and cosmetically
enhanced bodies. Philanthropy is also a characteristic of the city as is, generally, a
counterculture of environmental and social activism.
Santa Barbara is also a mecca for retirees. Fifteen percent of Santa Barbaras population is 65 years of age or older, compared to 13% nationally (U.S. Census Bureau
2010), and many use its numerous formal care institutions and services, which include nursing homes, residential care facilities, assisted care homes, continuing care
communities, convalescent care homes, specialized care facilitiessuch as for those
with Alzheimers diseaseand adult day care. In addition, many older citizens or
their kin seek in-home support services through private agencies, which supply the
more affluent with a range of care possibilities: from shopping and cleaning, to
companionship and medical care. For the less affluent, the states IHSS program
likewise provides some support. Many other aging citizens make use of a vast informal market of care, which includes a diverse range of possibilities from part-time
cleaning services to full-time, live-in care.
Santa Barbara is also home to Mexicans, whose history in the city predates the
U.S. conquest and whose presence has swelled with the arrival of thousands of immigrants in the last four decades. As the citys population has aged and the economy
has adjusted to neoliberalism, these trends have grown together. In the latter part
of the 20th century, Mexicans are recruited to labor in the service industry, including elder care. Seventy-five-year-old Ester Vargas epitomizes the Mexicana pioneers
who now dominate the elder care industry. Arriving in 1973, she remembers that
she quickly found a job at a nursing home. It was easyI just approached one of
the workers [outside the home] and I asked her for a recommendation. That same
afternoon I had a job. Ester, like other care workers, would become an important link for the migration of female kin and thus contribute to the growth of the

Frontline Activists: Mexicana Care Workers

439

Mexican population, which now constitutes at least 38% of the population of

88,000 (U.S. Census Bureau 2010).
Santa Barbara is my long-term field research site, and I have spent more than
six years in the field between 1994 and 2011. During that time, I interviewed 168
informal sector domestic workers, the majority of them elder care providers. My
analysis here is based on ethnographic fieldwork that took place during the summers
of 20092011, when I conducted open-ended and semi-structured interviews with
40 female and four male elder care workers, but it is also informed by work I
did between 19942001 and 20052007. During these previous research phases, I
addressed the configuration of suffering and possibility within informal domestic
employment.
I found that in private homes, Mexicanas, in one-to-one relationships with clients,
intentionally craft personalized care routines that include a complex range of emotional and physical labors (Ibarra 2002) and derive pride and spiritual rewards from
their work. Women, however, also speak of too much responsibility, too much fear,
and too little compensation (Ibarra 2003) and attempt to create better conditions
for themselves through group-centered care (Ibarra 2010). Throughout the different
phases of fieldwork, I attended many events where Mexican women gathered and
engaged in participant observation and informal conversations with workers and
their families. I used the snowball sampling method to identify hard-to-find informants (Bernard 2002) and regularly visited women in their homes where I compiled
life and care labor histories.
The range of care work that Mexicanas engage in is impressive, and in my last
period of fieldwork in 2011, I literally felt as if they powered the city. As I sat
at a local coffee shop, Mexican women walked by with their patients in strollers,
carefully managing their gaits. As I rode on a bus, Mexican women spoke about
how late they would be leaving their nursing home jobs. At a local charity function,
a caregiver waited in the back for his wheelchair-bound octogenarian employer.
At a grocery store, I saw Mexicanas following and helping their wards choose
different food items. I was invited to home-cooked dinners where three generations
of women spoke about elder care, and I ate at taco shops where caregivers gathered.
The hum of Mexicanas labor is constant and significantand yet, in spite of their
toil, womens lives are shadowed by insecurity. Mexicanas, like many care workers
nationally, typically have a patchwork of part-time jobs and high turnover rates
(Kemper et al. 2008). For Mexicanas in Santa Barbara, this pattern of constant
movement is a source not only of insecurity, but also of a disturbing understanding
about the formal care landscape, which becomes the context for activism.

Devaluation and Death: Mexicanas Problematize Formal Sector Elder Care

This was not made in one day. It was constructed over many years.
Teresa Maldonado (2011)
Mexicanas, whose careers had taken them in and out of the citys diverse formal
care industry, outlined a landscape characterized by devaluation and a moral opposition to it. Mexicana caregivers would say things like It is very common for people

440

Medical Anthropology Quarterly

to be mistreated. Or, It is a very brutal situation. When I asked what they meant,
womens answers were tied to a wealth of intersubjective care experiences. In diverse
settings, workers felt they had been introduced to a very different worldone in
which the devaluing of human beings is an everyday reality. In their concerns with
the formal sector, workers particularly addressed structural inadequacies, problems
with individual workers, the cultural values of Americanos, and the social abandonment of the elderly. They sketched a local moral world in which the imperative of
preserving life was foremost, yet there were constant failings.
A principal concern about formal sector institutions is their structural
inadequaciesnamely, the lack of supplies and time. In this regard, workers most
often discussed nursing homes, which vary in size throughout the city. Workers
were especially critical of homes where they claimed that poorer people received the
lowest service. In one such home, said Rosa, If someone urinated and needed a
new gown, there was no guarantee that there would be supplies, not even sheets.
Along with the lack of supplies was an inadequate amount of time to care for too
many people, a circumstance that leads workers to leave out important things. Likewise, workers spoke about supervisors who did not spend enough time assessing the
quality of the workers they hired. Anna Torres described coworkers who, lacking a
vocation, handled people roughly and spoke with disrespect. She was particularly
disturbed by an incident in which a worker knowing that someone [a patient] had
already died, didnt say anything, so as to not to have to deal with it. Anna went
on to say that, They treat people as if they were not people; as if they were things
without sentiments, like a piece of trash that can be thrown away.
The structural problems inherent in for-profit care have not gone unnoticed in
the broader community. At the beginning of the millennium, reportersfollowing
the trail of a protest suicide by a nurseuncovered what is described as abuse
in city nursing homes (Molina and Hadley 2000). This expose, in turn, framed a
period of crisis and demands for a decisive response, which led to the punishment of
the largest institution in the city. After a period of relative calm, new crises erupted in
2007 and 2008, when accusations of neglect surfaced at a convalescent care hospital
and an assisted care facility. In 2009, a judge ruled that the convalescent hospital was
liable for damages due to collective negligence and willful misconduct (Stewart
2009). In the summer of 2011, crisis again ruptured the perception of stability in the
citys care industry. The same nursing home fined in 2002, now under a different
name, continued to violate health standards and lost its operating license (Rosen
2011).
The problems in the formal sector are not limited to structural and worker-related
harm, however. Mexicanas said that another concern is with aging patients capable
of hurting others (Gas 2004). Workers felt they were on constant alert to protect
themselves and more vulnerable patients. In the opinion of Guadalupe, care facilities
are incubators of all that is and was part of society. She went on to say that,
Most of them [patients] are good . . . but some were bad . . . and they continue
into their old age. Over the course of her care career, Guadalupe had worked at
five institutions and had seen misogynists, racists, sexists, and homophobes. She
said, There I saw men who hated women, and their old age had not removed
this hate . . . they continued to hit. . . . Also I saw people who hated Mexicans,
who . . . spit in ones face. Others referred to male patients who harassed workers

Frontline Activists: Mexicana Care Workers

441

or assaulted female or gay patients. Alejandrina remembered that in one nursing

home, A manNelsonwas always approaching one of my patients who was
homosexual, and he would say very ugly things to him. She recalled that Nelsons
actions were made worse when a male coworker laughed, explicitly supporting the
belittling of her patient.
Another prevalent problem in the formal sector, from the perspective of workers,
is the lack of human warmth provided to patients by their families. Mexicanas were
very critical of Americanos who, in contrast to Hispanos, were perceived as being
very cold. In a joking manner, typical to a public telling of an emotional moment
(Tate 2007), one worker described a gathering after the death of a patient at a private
home where four workers from a private agency were employed: The family was
there, which is rare, and they were very quietno one was crying. And behind
them were the Mexicansall of us were crying! Here she interprets the visible
display of emotions as a sign of caring for another and therefore her belief that
Americanos do not care.2 Although this interpretation is obviously skewed, it arises
from very specific social conditions: Socially segregated Mexicanas often only know
the context of those families who pay for care; few have insight on or relations
with those who do not. This lack of substantive interaction with Americano family
members in the formal sector likewise leads workers to propose another trait that
leads to the devaluation of the old: Americanos are more interested in money than
people. Benita said, I know of people who even though they live here never visit [a
relative], because they are always working.
For many Mexicanas, this cultural coldness, in turn, contributes to what they
see as an essential problem in the formal sector: Human beings are banished from
their known social group to live in isolation until their death. Marina said, Their
families forget about themthey say, Someone else is responsible. . . . That is
an injustice, so many abandoned souls. Martina echoed Marinas thoughts, The
elderly extend their hand to you, they need company more than anything and human
warmth. Those machines in there [a convalescent care facility] are very cold, but so
are the people. Other workers were likewise moved by the social plight of elderly
patients: Teresa said, They dont have family members to visit themthey are too
far away or they work. And Rosa said, I met so many people so alienated from
the warmth of their families, and I wanted to take care of themfor me care is a
vocation and an honorbut the work is very heavy.
Mexicanas are not unique in believing that to be alone at the end-stage of life
is both commonplace and deplorable. The normality of social isolation within
formal sector care became part of a public conversation when a good Samaritan,
responsible for exposing nursing home conditions, spoke out. Seventy-year-old Edmund Finucane said that hed been visiting nursing home residents for 28 years,
since he had been moved by a handwritten sign on a window that said, Come visit
us. This sense of pathos is also apparent in the names of programs created by the
nonprofit Hospice of Santa Barbara. These names evoke an alternate vision for the
end of life: People should be able to engage in Life Reminiscence with Spiritual
Companions, and, significantly, be in a place where No One Dies Alone.
Equally as disturbing as seeing someone alone in formal sector settings is knowing
that a patient has died alone or with a stranger. Lourdes, employed by a private care
agency, spoke of such an experience. She was sent to a private home as a temporary

442

Medical Anthropology Quarterly

replacement. As she approached a bed in a darkened room, a man suddenly opened

his eyes and reached out for her. Worried, she quickly met his arms. She held him
as he said something she could not understand, then he closed his eyes and died.
In shock, she called her supervisor who was sympathetic but told her to go ahead
and prepare the body. Lourdes said, I never imagined I could feel so much sadness
for another personfor a person so alone that they had to die in the arms of a
stranger.
Hers was not a unique experience. Jaclyn said she had been sent to care for a
93-year-old woman, as a temporary replacement for a worker who was ill that day:
I arrived in the afternoon, and Ill never forget the smell of her room. It
smelled like someone had been sick for a long time. . . . I went to her, my
heart beating so fast, because I had never been with someone who looked
that sick. I spoke to her and told her I was going to get clothes to change her,
and she just closed her eyes. When I came back, she was already dead. What
pain one feels. . . . I felt I should have known, that I should not have left her,
and then she would not have died alone.
In attempting to explain what they were seeing and experiencing, Mexicanas,
whose care careers have taken them in and out of different formal care settings,
expressed concern not only with specific places but also more broadly with a collectivity of settings. When Teresa said, This was not made in one day, she referred
to what she sees as a deeply problematic landscape of formal care.3 Within this
landscape, some workers also describe their own conflicted roles and the links to
their own subjective vulnerabilities.

Subjective Feelings
What are the human consequences of working in medical care settings where suffering takes place on a daily basis? One study describes being a nurse as a lonely
and enduring struggler trying to act in the patients best interest (Hov 2009:656).
Caring for patients where end-of-life questions are in focus can, in particular, be so
disturbing that some nurses want to change their occupation or lose their appetite
and feel pain (Hov 2009). When nurses caused needless suffering to patients, they
thought of themselves as tormentors and felt professional shortcomings and guilt
(Hov 2009). Likewise, many Mexican caregivers felt anguish at the thought of going
to work, especially where death was an everyday occurrence. Gloria, employed at
a nursing home said, It is very difficult everyday there is something that shakes
you. . . . I became very depressed. I no longer saw hope.
Some workers felt shame tied to a sense of complicity with the structure of work.
To come to see oneself as complicit in the suffering of others did not mean that
a worker willingly performs as shes told (Wengler 2003)in fact, most women
described themselves as unwilling participants, caught up in the requirements of
management. Martina said, You start work and they tell you, as an example,
Take care of twelve people . . . and to finish you have to eliminate many things.
Another woman, Raquel, said, I always felt very badly therehow many of those
poor people asked for something so simple from me? Please, could you give me

Frontline Activists: Mexicana Care Workers

443

something to eat? But you were not allowed if it was after mealtime. Or worse,
when you could see that they needed to be moved, but you couldnt do it, there
wasnt time.
The impending death of a person weighed heavily on women. When I knew
that they were going to die, it ripped my soul. I knew that they needed someone
there, but what could I do? asked Raquel. Another worker, in reference to death,
said, At the beginning I was really affected, but I learned to close myself in order to
suffer less. Raquel said that this strategy of closing oneself is fraught with danger
because, If youre not careful and sensible to the fact that these are real people,
with real feelings, you come to treat them like a case.
Some women expressed remorse for things left undone. Cecilia said, I began
to feel like a bad person, I would go home and that feeling stayed with me. My
husband tried to help by saying just forget about it, but how does one forget so
much devaluing? I could not. Other workers expressed feeling nervous, in a
state of constant anticipation of that feeling, that they were doing something
very wrong. Many felt that they had left a human being in an incomplete way,
and others felt they were breaking with engrained codes and values. Marina said,
I grew up in a family of people who were evangelistswe learned to give and to
work for the dignity of human beings. Here I saw myself doing the opposite. The
sense of lack of control was also very strong: Many often said, I did not want to
do this job, but at the same time they said they could not find other work in the
city.
A sense of complicity and the shame and remorse that it produced, for many
women, went against their moral grain. These feelings also intertwined with their
own subjectivities as displaced people, who, likewise, were very often unwilling
participants in the circumstances of their migrant lives. Tomasa said:

One sees so much suffering and also one remembers having suffered. One
doesnt like to talk about these things, but sometimes they have to be said.
. . . They dont recognize what the Hispanos have to go through just to be
here. And when you know that, when you have lived it in the flesh, you
recognize it, you see it [in others] and it is impossible to live with such a
weight, that you too are causing them harm.

Womens expressions of identifying with their patients are gripping. Forty-twoyear-old Angelica, who had migrated in 2007 from a town in Zacatecas mired in
narco-extortion, said, I looked at that person and said to myselfthat could be
you. She described a patient with dementia who had moments of lucidity, and
who in one of these moments looked around and cried, Why am I here? Angelica
could feel the terror of a person who is trapped, and related her own story. I have
felt the same way in many moments, especially when I came across [the border]. I
felt out of myself. . . . I was there physically but I could not conceive it.
Likewise, 47-year-old Maria, who had migrated from an economically distressed
town in Durango in 2001, told a story of entrapmentin this case, entrapment made
bearable by false illusions. She said:

444

Medical Anthropology Quarterly

There was a woman that I came to loveit did not matter how many bad
things happened to her . . . she maintained that illusion that her stay there
[residential care] was only for a little while, that her daughter would come
back. And thats how we are as Mexicans, right? We live with that illusion
that one is going to return even though we know there is no future there.
In contrast, Sara Contreras, a 51-year-old migrant from Michoacan who had
migrated in 1999, could see her future in the experience of patients without family.
I said to myself, this is going to be you. . . . I no longer even have a husband and
my children have grown up in wandering. Who is going to take care of you? You,
too, will end up as an abandoned person.
Others said poignantly that seeing a vulnerable older person abandoned was
a reminder of their own aging kin left behind and of the moral weight of that
separation. How I would have loved to have taken care of my mother . . . but
I was never able to see her again after I left, said 38-year-old Renata. She had
migrated from the state of Guanajuato in 2004, when it became necessary to earn
money to pay for her mothers medical treatments. Because the border crossing was
so dangerous, she had not returned to Mexico, even when doctors did not hold
out hope for her mothers survival. Renata said, I felt so much indecisionI told
myself that doctors arent always right and if I left and she continued living, I would
have lost my job and the money to continue her treatments. But I chose wrong. . . .
I have to live knowing that I wasnt there for her at the end.
Other workers took solace from working in settings where patients had a condition or illness similar to that of a parent: I wanted to work there [an Alzheimers
facility] because I felt closer to my mother; I also felt an affection for them because
they were teaching me how to treat my mother. . . . I wanted to learn all that I could
so that I could help her. Thus, workers movingly and explicitly see the parallel
between the plight of their own parent and the person in the care facility.
In accounting for their presence in formal care settings where devaluation takes
place, workers empathize with patients, who like them, are displaced persons at the
bottom of the social hierarchy. In this reality, when workers come to see themselves
as complicitalbeit unwillinglyin what they perceive as victimization of another,
they experienced irreconcilable feelings of shame and remorse, which, in turn, helped
shape Mexican women as activists.

Frontline Activists: Defending Others

I feel the abuse; it should not exist. For me it is unacceptable. I am a person
with a lot of love.
Gloria Trujillo (2011)
In the face of a formal care sector, which many workers see as immoral and in
which their own subjectivities as displaced persons are intertwined with that of their
patients, some workers rise to the defense. As Tania said, There comes a point
when you, you yourself not someone else, have to decideI am going to do this
or not. Because at the end of the story it is you who have to live with what youve

Frontline Activists: Mexicana Care Workers

445

done or not done. Workers resistance takes many forms, but can be divided
into actions that involve outside agencies; direct, everyday forms of intervention
within the workplace; and the creation of alternative care in the informal sector.
Here I address two direct forms of defense in the formal sectorprovisioning and
teachingand the creation of alternative, informal family-based care in private
homes.

Provisioning
One form of everyday resistance is to challenge institutional scarcity through provisioning. Workers particularly recognize a scarcity of time to fulfill a range of
perceived needs. One of these needs is grooming, especially trimming nails and
arranging hair. Raquel said, The aspect reflects the carethese persons are not animals; you cant just wash them down and leave them. When a supervisor denied
a request for overtime, Raquel instituted her own once-a-month nail-clipping visit
on a day off. She came in with one of her daughters who provided conversation,
while she worked on nails. She said, Of course I would prefer to be paid, but if
they wont pay, what do I do? They are a reflection of me. . . . One can see it as an
act of charity and also as an act of humanity. For Raquel, a broader imperative is
to maintain the dignity of individuals by caring for their bodies in a way that marks
them as non-animals.
Other workers stayed after work simply to sit with patients, especially those
who they perceived as the loneliest or closest to death. As Mariela said, When
my hours are done, the feeling of responsibility doesnt end. Some of the most
moving accounts were of death vigils: of workers next to a bedside, holding a hand,
rubbing a forehead, and bearing witness to the fragility of life. Here, the imperative
of honoring life and valuing the individual at their most vulnerable point were
foremost in womens minds.
Some workers also insisted on ritually marking death, to uphold the significance
of the person. Celestina, who had been employed at a nursing home, said:
Many of us, as Christians, came to believe that it was necessary to do
somethingnot just see the body and keep walking. Not everyone died like
that [alone]sometimes there was a priest from their religion or someone
from the hospice. But when there wasnt someone there, or if someone [a
worker] had cared for that person, what we did was quickly organize
ourselvesthree or four, or whoever could be thereand at the side of the
personone of us would say a prayer. It was not in their language, but God
doesnt care about that.
In addition to resisting the scarcity of time, workers also sometimes resisted
material scarcity. Rosa, for example, had complained for weeks about a recurring
problem with a lack of sheets and hospital gowns during her evening shift at a
nursing home. When she realized action was not immediately forthcoming, she
took it on herself to buy thrift-store sheets, wash them, and then bring them in
with her. If supplies ran out, she would not let her patients lie naked in the night.
Alicia, at a smaller residential care facility, likewise complained and was faced by

446

Medical Anthropology Quarterly

inaction. She then appealed to women in her church to knit small blankets. In other
instances, workers employed through home health care agencies, provided food or
desired luxury items such as magazines, lipsticks, or music. To provide in this way
signified, once again, the importance of the individual and their personal integrity.

Education
Some workers say that ignorance causes suffering and that education is a way to help
change this reality. Some believed that if the patients family members understood
how much the aging person needed company, they would provide it. These women
took it on themselves to speak. Alejandra commented on this, saying:
There were people who appreciated and even thanked meone daughter
cried and apologized to meand sometimes it made a difference. . . . Others
saw me as an intruder, and one, she was really mad, said to me, Who are
you to tell me anything? This is none of your business.
Sometimes, as well, defending patients meant that workers resorted to teaching
through shaming a fellow worker. Alejandrina became enraged when she saw a
coworker laugh at a homophobic comment made by a patient against her own
patient. She sought out this coworker and said to him, That man, what has he
done to you? Nothing. But you humiliate him and give strength to the other. That is
not being a man. Other workers spoke about group tactics. For example, Renata
and a coworker, to get a third worker to stop the brusque handling of patients at
a residential care home, took photographs with cell phones. Renata said: She was
really mad . . . she said she was going to split my mouthbut she knew what we
had.
To participate in these forms of defense clearly involves sacrificewomen give up
time and resources, and in negotiating with supervisors, coworkers, or the patients
family members, they may face hostility, anger, and even physical threats. In some
cases, workers have been fired from their jobs or demoted. But resistance is also
sometimes a source of rewards: Internally, some women felt very full, very
good, very comfortable, very satisfied that they had done the most that they
could. Workers also spoke about the emotional rewards of working for something
bigger than themselves, of seeing injustice and trying to change it. Still others
spoke about gaining recognition within the workplace, among their families, and
within their church. Cecilia said: We are known as honorable people.
Many women, likewise, also spoke in a tone and in a language that parallels
what others call compassion fatigue (Tate 2007). This work is very tiring, it
takes everything from you, said Elizabeth. Bertha said, I feel like anything will
make me cryI was not like that before; I know that its the stress of this job.
Teresa emphatically told me, I dont know how much longer I can do this. . . . I
feel compromised on all sides. These quotes illustrate the emotional strains, which
sometimes lead to the creation of something newan alternative form of caring
that might, in womens fondest hopes, eliminate what they see as the devaluing of
patients and of themselves.

Frontline Activists: Mexicana Care Workers

447

Informal Family-Based Care

Unique to Mexicana caretakers in Santa Barbara is their formation of alternative
informal arrangements, including family carewhich consists of related individuals
who collectively care for aging patients in private homes. Family groups are directly
hired and paid by the patient or a family member. Most of the workers are women,
but some are men. In my sample, seven out of 44 workers were involved in this type
of care. The smallest family group consists of two people, and the largest consists of
seven. The size of the work group determines how many individuals can be cared for,
as does the extent of patient need. Patients are characterized as being very wealthy
to normal, not wealthy, and the per-hour payment ranges from $10 to $21.
Workers typically worked one-on-one with patients during their respective shift,
but sometimes there is a need for more than one worker at a time. The organization
of work, including the number of workers at any given time, is collectively determined based on overall patient need and worker qualifications. Not all workers
within the family group labor for an equal number of hours per week, nor are they
all equally qualified. In the largest group, three of the members held certified nursing
assistant licenses and they were insistent that they were the only ones who took on
certain responsibilities, including the overall monitoring of a patients health. Other
members, with less experience, were assigned different tasks that included cleaning,
laundry, companionship, grooming, and overnight shifts.
All of the workers who had initiated family care were deeply disturbed by what
they had experienced in formal sector settings and had felt shame, complicity,
and empathy for aging patients. Only one worker explicitly identified herself
as an activist, but all expressed a desire to create a better form of care, one in
opposition to what they had experienced in the formal sector. Significant to all
of the seven cases is an initial realization by a worker of an opportunity to create
something different as well as the ability to engage other family members to labor
alongside her.
Next, I provide excerpts from an interview with Gloria who created such a
group and who identified herself as an activist. Gloria, a 52-year-old retired teacher
from Zacatecasa state with warring cartels, a strong army presence, and ongoing
violenceexplains why she left Mexico, her trajectory as a care provider, and
ultimately the realization that she had an opportunity to start something different.
Gloria said about leaving Mexico in 2007: I stayed to care for my mother, but
after she died I felt like my Mexico had become an empty frameone cannot live
with so much poverty and so much fear . . . my husband and sons had already left
[for the U.S.] and here is where I saw my destiny. She continued:
I started at a nursing home . . . and also two days a week at the house
[residential care facility]; later I started to take care of Helen [in Helens
private home] . . . [Helen] was 88 and looked well. . . . When she asked me
to help her [full-time], I saw this as an opportunity to leave the other places
and dedicate myself to truly helping her. What one sees in those other places
forces you to revalue your life. You ask yourself, do you want to work for
good or do you want to continue in the same way? . . . I wanted to work for
the good.

448

Medical Anthropology Quarterly

Gloria then recounts how family group care developed with her first full-time
patient:
I started to work with her every day, normally about nine hours a day, and it
still wasnt enough. But it was very hard with my familyI never saw them.
. . . Later my sister-in-law took the week-ends [to give Gloria time-off] . . .
and when Helen didnt want to be alone at night, my husband started to
help [spending the night at Helens home].
In recounting how the work makes her feel, Gloria said:
It was the first time since I came to this country, that I felt satisfied. The
work made me feel wellthis is how I cared for my own mother. . . . I also
felt useful. . . . I felt very united with my family . . . and I no longer feel that
burden that I felt at the other places. . . . Here I can dedicate myself to her,
and attend to her as a human beingwith compassion with patience.
How did the family based-care arrangement grow?, I asked Gloria. She replied:
One of Helens neighbors learned about us, and one day she asked me if we
could help her. And that was truly the moment of inspirationwe could do
something different here. . . . I felt that I could give myself to something that
truly matters. . . . Slowly, slowly we began to look for another person [to
care for] and thats when we met Helens minister [during a home visit to
Helen]. . . . He said to me, You and your family are angels. And later he
called me to see. . . . Mr. Barry [a parishioner living independently in his
home]. . . . We now take care of three people, and thats all.
Then I asked: How is this work different from working at the nursing home or
care facility? Gloria said:
Its a difference like that of night and day: Here I feel that I have the time to
take care of this person. . . . Also, Im not always carrying sadnessyes,
theyre old and not as strong as they used to be, but thats normal, if you
know that theyre well cared for. . . . Everything thats in our capacity to
give, we give it. And unless family members make other decisions, well stay
until they no longer need us. . . . For me, that is very beautiful.

Conclusion
In this article, I focused on Mexicana frontline silent activists, whose everyday forms
of defense on behalf of their elderly patients go unseen and unheard in the broader
society, but that collectively add up to a rejection of the devaluation that these
women see in many formal contexts. The incongruity of women at the bottom of
the social hierarchy defending citizens of the nation is partially explained through
examination of womens subjectivity as shaped by their experience as migrants and
as workers, intimately and intersubjectively engaged. In many local care settings,

Frontline Activists: Mexicana Care Workers

449

Mexicanas come to feel empathy for their patientsthey recognize that their patients suffering parallels their own: That could be me or someone close to me.
This feeling, in addition to the shame and remorse of complicity, help us understand
why some women defend the Other. Defense takes many forms, among them informal family-based care, which rejects a bare minimum model and puts into practice
a patient-centered model where the key imperative is not only to sustain life, but
to give the life thats left dignity, affection, compassion, and time. And by so doing, perhaps, workers also create for themselves a life that has dignity, affection,
compassion, and time.

Notes
1. Nurses and aides also exercise deliberate resistance to the person-centered nursing
home model, created in response to the critique of institutionalized care (see Lopez 2006).
2. Although the worker here had a close relationship with the deceased, for-profit
private home care agencieslike care institutionsnow commonly dictate that closeness
not develop between patients and workers so as not to risk losing the client to the caregiver
as a private patient (McLean and Trakas 2010).
3. Many scholars have likewise noted profound problems in long-term care, especially
in institutions. (see, e.g., Eckenwiler 2012; GAO 2005).

References Cited
Ahearn, L. M.
2001 Language and Agency. Annual Review of Anthropology 30:109137.
Bernard, H. R.
2002 Research Methods in Anthropology, 3rd ed. Walnut Creek, CA: AltaMira.
Biehl, J.
2005 Vita. Los Angeles: University of California Press.
Biehl, J., B. Good, and A. Kleinman
2007 Subjectivity: Ethnographic Investigations. Los Angeles: University of California
Press.
Boris, E., and J. Klein
2012 Caring for America. New York: Oxford University Press.
Chang, G.
2000 Disposable Domestics. London: South End Press.
Chin, M.
1998 In Service and in Servitude. New York: Columbia University Press.
Constable, N.
1997 Maid to Order in Hong Kong. Ithaca: Cornell University Press.
Dave, N.
2011 Activism as Ethical Practice. Cultural Dynamics 23:320.
Decasus, Y.
2011 Santa Barbara: Santa Maria Cant Afford More Cuts. http://www.udwa.org/2011/
12/santa-barbara-santa-maria-cant-afford-more-cuts (accessed February 17, 2012).
Degiuli, F.
2007 A Job with No Boundaries: Home Eldercare Work in Italy. European Journal of
Womens Studies 14:193207.
Diamond, T.
1992 Making Gray Gold: Narratives of Nursing Home Care. Chicago: University of
Chicago Press.

450

Medical Anthropology Quarterly

Eckenwiler, L.
2012 Long Term Care, Globalization, and Justice. Baltimore: Johns Hopkins University
Press.
Folbre, N.
2001 The Invisible Heart: Economics and Family Values. New York: The New York
Press.
Foner, N.
1995 The Caregiving Dilemma: Work in a Nursing Home. Los Angeles: University of
California Press.
Gas, T. E.
2004 Nobodys Home. Ithaca: Cornell University Press.
Giddens, A.
1993 Problems of Action and Structure. In The Giddens Reader. P. Cassell, ed. Pp.
88175. Stanford: Stanford University Press.
Gordon, S.
2005 Nursing against the Odds. Ithaca: Cornell University Press.
Government Accounting Office (GAO)
2005 Nursing Homes: Despite Increased Oversight, Challenges Remain. In Ensuring High Quality Care (GAO-06117). Washington, DC: Government Accounting
Office.
Gunewardena, N., and A. Kingsolver
2007 The Gender of Globalization. Santa Fe: School for Advanced Research Press.
Harvey, D.
2005 Spaces of Hope. Los Angeles: University of California Press.
Hochschild, A.
2003 Love and Gold. In Global Woman: Nannies, Maids and Sex Workers in the
New Economy. B. Ehrenreich and A. Hochschild, eds. Pp. 1530. London: Granta
Books.
Hondagneu-Sotelo, P.
2001 Domestica. Los Angeles: University of California Press.
Hov, R.
2009 Being a Nurse in a Nursing Home for Patients at the Edge of Life. Scandinavian
Journal of Caring 23:651659.
Ibarra, M. de la Luz
2000 The New Domestic Labor. Human Organization 59:452464.
2002 Emotional Proletarians in a Global Economy: Mexican Immigrant Women and
Elder Care Work. Urban Anthropology 31:317350.
2003 The Tender Trap: Mexican Immigrant Women and the Ethics of Elder Care Work.
Aztlan:
A Journal of Chicano Studies 28:87114.
2010 My Reward Is Not Money: Deep Alliances, Spirituality, and End of Life Care.
In Intimate Labors. E. Boris and R. Parrenas,
eds. Pp. 117131. Stanford: Stanford

University Press.
Kemper, P., B. Heier, T. Barry, D. Brannon, and J. Angelelli
2008 What Do Direct Care Workers Say Would Improve Their Jobs? Differences across
Settings. The Gerontologist 48:1725.
Kleinman, A.
2006 What Really Matters: Living a Moral Life amidst Uncertainty. New York: Oxford
University Press.
Kleinman, A., and E. Fitz-Henry
2007 The Experiential Basis of Subjectivity. In Subjectivity: Ethnographic Investigations.
J. Biehl, B. Good, and A. Kleinman, eds. Pp. 5265. Los Angeles: University of
California Press.

Frontline Activists: Mexicana Care Workers

451

Lichtenstein, N.
2003 State of the Union. Princeton: Princeton University Press.
Lopez, S.
2006 Culture Change Management in Long-Term Care: A Shop-floor View. Politics and
Society 34:5579.
McLean, A.
2007 The Person in Dementia. Toronto: University of Toronto Press.
McLean, A., and D. J. Trakas
2010 Beyond Impediments to Caring: Toward a Morality of Late Life Care. Medische
Antropologie 22:1330.
Molina, J., and S. Hadley
2000 Abuse in Nursing Homes. Santa Barbara News-Press, September 24: A14.
Nakano G. E.
2012 Forced to Care: Coercion and Caregiving in America. Cambridge: Harvard
University Press.
Ngai, M.
2003 Impossible Subjects. Princeton: Princeton University Press.
Oberle, K., and D. Hughes
2001 Doctors and Nurses Perceptions of End-of-Life Decisions. Journal of Advanced
Nursing 33:707715.
Ong, A.
1987 Spirits of Resistance. Albany: SUNY Press.
Ortner, S.
1997 Thick Resistance: Death and the Cultural Construction of Agency in Himalayan
Mountaineering. Special issue, The Fate of Culture: Geertz and Beyond. Representations 59:135162.
2004 Subjectivity and Cultural Critique. Unpublished manuscript, Department of
Anthropology, University of California Los Angeles.
Parrenas,
R.

2001 Servants of Globalization. Stanford: Stanford University Press.

Romero, M.
2002 [1992] Maid in the U.S.A. London: Routledge.
Rosen, B.
2011 Nursing Home Whistleblowers Unsung Story. Santa Barbara Independent, October 3. http://www.independent.com/news/2011/oct/03/nursing-homewhistleblowers-unsung-story (accessed February 17, 2012).
Rylko-Bauer, B., and P. Farmer
2002 Managed Care or Managed Inequality: A Call for Critiques of Market Based Care.
Medical Anthropology Quarterly 16:476502.
Sassen, S.
1988 The Mobility of Labor and Capital. Cambridge: Cambridge University Press.
Scheper-Hughes, N.
1993 Death without Weeping. Los Angeles: University of California Press.
2007 Violence and the Politics of Remorse. In Subjectivity: Ethnographic Investigations.
J. Biehl, B. Good, and A. Kleinman, eds. Pp. 179234. Los Angeles: University of
California Press.
Scott, J.
1985 Weapons of the Weak: Everyday Forms of Peasant Resistance. New Haven: Yale
University Press.
Stacey, C.
2011 The Caring Self: The Work Experiences of Home Care Aides. Ithaca: Cornell
University Press.

452

Medical Anthropology Quarterly

Stewart, E
2009 Terrace of Trouble? Jury Awards $2.2 in Elder Care Lawsuit. Santa Barbara NewsPress, June 25. http://www.independent.com/news/2009/jun/25/terrace-trouble/
(accessed August 23, 2013).
Tate, W.
2007 Counting the Dead: The Culture and Politics of Human Rights Activism in Colombia. Los Angeles: University of California Press.
U.S. Census Bureau
2010 State and County Quick Facts. http://quickfacts.census.gov/qfd/states/06/
06083.html (accessed February 22, 2010).
Wengler, D. B.
2003 Code Green: Money Driven Hospitals and the Dismantling of Nursing. Ithaca:
Cornell University Press.
Wood, E. J.
2003 Insurgent Collective Action and Civil War in El Salvador. Cambridge: Cambridge
University Press.

Copyright of Medical Anthropology Quarterly is the property of Wiley-Blackwell and its

content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.