The United States is facing a significant and growing crisis in its long-term care workforce. As the population ages and the need for long-term care grows, so, too, does the demand for workers to perform this difficult, low-status work. Indeed, projections cast direct-care workers (such as home health and personal care aides) as the fastest-growing occupations in the country. Thus, the book under review addresses a critical issue faced by the United States (and other developed nations): the importation of long-term care workers—nurses and direct-care workers—from abroad, and the moral issues raised by this reliance on emigrant workers.

The author, a Professor of Philosophy at George Mason University, uses a philosophical perspective to describe this phenomenon and the issues around it, espousing an “ecological” approach. This considers the interrelations among and interdependency of individuals and groups; identifies broad patterns while recognizing individuality; is sensitive to power relations; and lastly, takes a “longer temporal and spatial view.” The perspective, in other words, makes fairly broad and ambitious claims.

Are these ambitions realized? The book does indeed take a broad view and ties together a great deal of information. As such, it provides a much-needed overview of the issues raised, both for the United States and the workers' countries of origin. There is no doubt that this is an important phenomenon with wide-ranging implications: 48 percent of registered nurses working in home care are from abroad, while 20 percent of direct-care workers are foreign-born. The importation of skilled care, in particular, deprives source countries of much-needed medical expertise, expertise that was often the result of public investments that are lost when individuals emigrate. Direct-care workers, on the other hand, often suffer from low wages and poor working conditions once in the United States.

Given the ambition of the effort and the range of issues covered, however, it is a surprisingly short book. I yearned for more depth and greater appreciation of the complexity of (and existing research on) some issues. For example, references to consumer-directed care failed to cite studies that would have allayed the author's concerns about its impact on family caregivers and workers. Similarly, the author discusses difficulties faced by family caregivers without linking these to her overall theme: how exactly are these very real issues associated with emigrant workers? Is it implied that if there was more support (in terms of family leave and so forth), this reliance would be reduced? In fact, countries such as Germany that have “maternalist” social policies also rely heavily on emigrant workers to provide long-term care. Indeed, the relationship of such social policies to the roles of women and workers is a subject of a considerable literature, not referenced in the book. Moreover, the truly global nature of this issue is unexplored—the fact that countries as diverse as Austria, Italy, Germany, Taiwan, and Singapore rely even more heavily on emigrant care workers than we in the United States do.

The book concludes with a laundry list of desired policy changes, and calls for mutual respect and empathy among key stakeholders. Overall, it provides a valuable function in highlighting an important issue and provoking readers to appreciate its complexity and the moral issues raised. The book is somewhat frustrating, however, in its obfuscating language and broad demands for change in the absence of practical prescriptions for implementation, and its downplaying of work already conducted and the considerable barriers to progress that exist.

  • Pamela Nadash

  • University of Massachusetts Boston