Written by: Pat Armstrong and Susan Braedley

Tumultuous times offer opportunities for transformation. Pandemics, like wars and other tumults, not only expose vulnerabilities and inequities, but offer possibilities for developing collective strategies based on shared needs and responsibilities. The necessity and opportunities for such transformation have become obvious in those places variously called long term residential care, care homes and nursing homes. High death rates resulting from the combinations of COVID-19 isolation, and horror stories of neglect,  along with critical shortages in care staff, have called attention to these homes in ways seldom seen before, raising demands for new strategies for older people’s care -including demands to eliminate care homes altogether.

In Care Homes in A Turbulent Era: Do They Have a Future?  we consider whether and how care homes could be transformed to offer conditions of dignity and respect for all those who live in, work in and visit in nursing homes.  But we go further, to ask, can care homes be transformed to promote pleasure and joy? Our answer to these questions of care home transformation is YES.  But we offer caveats and cautions about the challenges ahead.  Addressing care home issues is not a merely matter of repair or minor reform, although both could provide improvements. To achieve the goals of dignity and respect, care homes need a revolution. This book sets out ways forward. In doing so, it attends to context and populations as well as to other global and local forces, offering ideas worth sharing and promising practices rather than a single model or right way for care homes in the future. And it includes everyone who lives in, works in, manages, and visit in care homes.

This book is innovative in a number of ways.

First, our research team and the methods we employ are innovative, providing an interdisciplinary, international approach to care home questions.  It includes sociologists, social workers, nurses, anthropologists, historians and more who have been researching together on care homes for more than 15 years., Over this time, we have developed enough trust to challenge each other about important issues in ways that help us move forward. We embrace diversity and differences in our group, seeking to learn from these differences.

Our diversity in disciplines and educational backgrounds is our strength, providing us with multiple ways of perceiving care home issues. This not only means that we capture more than we would individually but, in working together, each team member developed a more multifaceted understanding as we learned from and with each other. Our mixed methods (discussed in Armstrong and Lowndes 2018 Creative Teamwork: Developing Rapid Site-Switching Ethnography) also means that we are always comparing and assessing data gathered in different ways, seeking complex, nuanced analyses to inform change.  

Our research teams include those who investigate the available statistical, financial, and other quantitative data available on nursing homes, those who research the history of nursing homes, and those who investigate ownership and other aspects of nursing homes. But unusually, in this project most of our team members –including our most senior members –have spent a long time conducting research in care homes. In six countries and in multiple cities and towns, our teams of about 12 researchers interviewed, observed, and participated in care home life. We worked in teams and shifts, starting at 7 am and continuing until midnight each day throughout the course of a week. Each team included locals and members from the other countries in our project, allowing us to draw on knowledge of the local context as well as on new perceptions from those less familiar with the country and place. Our collective analysis during and after these site studies located our findings within the research we also did on the forces and structures, policies, and practices shaping what we saw and heard.

Second, we assume context matters. In our research we were not seeking care home best practices or one right way. Instead, we aimed to identify promising practices and ideas worth sharing from Canada, Germany, Norway, Sweden, the UK, and the US, while acknowledging the possibility of not finding anything promising. We also learned how hard this is, given that our training focuses more on finding and analyzing problems.

Third, we assume that gender, race, sexuality, and class matter, and not just at the level of individual residents and staff, but as factors shaping care and work at the levels of organizations, systems, and states. And these social relations always matter, albeit in different ways, at different times and in different relationships

Fourth, our concept of care understands care as a relationship. From our perspective, this relationship involves all those who live in care homes, who provide paid and unpaid care in them and who visit in these homes. So, we include not only families and residents but also volunteers and housekeeping, dietary, laundry, security, and managerial staff. In contrast to both those who conceptualize care for this population as the inevitable domination by carers over those who require support, and those who focus exclusively on the needs of either residents or staff, we perceive care as a relationship of mutual trust and respect, requiring conditions that allow care to flourish.  For us, the conditions of work are the conditions of care.

Fifth, and perhaps most importantly, we assume that care homes are not only socially necessary. They can, and indeed should, be places that put life into years rather than years into life, places where people are choose to live and work.

This book draws on our many forms of data, together with our reflections and contemporary debates about nursing home care, going beyond specific evidence to dare to dream about promising ways to practice long-term care.

Avoiding prescriptive formulas and in keeping with our understanding that contexts and populations matter, we do not set out a new care home model. Rather, we identify key principles and some critical ingredients that can be adapted to specific contexts. We invite readers to dare to dream with us, taking inspiration for the care home transformations so badly needed.

What do we suggest? We argue that publicly funded and operated nursing homes have the highest potential to offer the most cost effective, high quality, accessible, and equitable nursing home care. In our chapter on financialization across the care home sector internationally, the tensions between profit and care become clear across the system. Further, the chapter reveals how accountability for care is disappearing in the maze of increasingly complex ownership arrangements across borders that make it difficult to identify who is responsible for a specific care home.

Further, working conditions need to be central to any revolution in care. All staff-including not only those who provide direct nursing care but also those who cook, clean and do laundry need the time, training, teamwork, autonomy, consistent assignment, and  supportive supervision to develop knowledgeable care relationships with residents. This is not possible unless workers have secure employment and sufficient pay to stick with care home work, and conditions that allow them to go home knowing they have provided care, and not just a bare minimum of bodily maintenance. And we must also attend to the working conditions of those who do unpaid work as family, friends, and volunteers.

Over and over, we have found that care homes’ physical environments matter. Important to infection control, safety, welcome, comfort, and mobility, physical environments can also make access to the outdoors inviting and pleasant, provide a sense of belonging in its colours, artwork, symbols, and architecture, make it easier for workers to respond to resident needs, and support families to enjoy their visits with residents. Homes need to bring the outside in and the inside out, integrating with rather than separating from the community. Care homes are not individual dwellings but collective ones, and physical environments need to welcome, reflect, and support all who live, work, and visit them.

We argue that the future of care homes is contingent on whether and how equity and diversity are addressed. Our research shows that care homes have the potential to be collaborative, culturally diverse, equitable organizations with deep, daily connections to the diverse communities and groups who live around them and review promising approaches that can advance this goal.

How accountability is understood, developed, and embedded in processes is also important to care, and not just accountability to funders, but to residents, workers, families, and communities. Instead of reviewing the research on regulation and accountability, one chapter approaches these issues through interviews with those who have spent years studying care homes in multiple countries. More a conversation than a standard academic approach, the participants explore the lessons learned and questions to ask.

And finally, we argue that joy is central to quality in care homes. We discuss ways in which quality assurance methods both support and fail to measure quality of life, quality of relationships, and opportunities for meaningful sharing and pleasure that include all who live, work, and visit care homes. Our analysis includes supplemental or alternative approaches to ensuring quality in care homes, encouraging all those concerned with care for older people to consider the problem of quality by beginning with joy.

Locating the analysis in the research and perspectives of multiple disciplines and scholars from multiple countries, the book challenges readers to go beyond what’s wrong to think about how to make care homes a positive option for provide those who need such care and those who provide it.

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Written by: Martin Caraher

The food insecurity crisis is characterised by the triple burdens of malnutrition, of which undernourishment is just one aspect, it also includes micronutrient deficiencies and overnutrition. Globally, over 821 million people suffer from undernutrition, 2 billion people with micronutrient deficiencies and over 2 billion adults are overweight or obese. In some economies obesity can be seen as a proxy indicator of the new food insecurity, as populations consume more processed foods and less fruit and vegetables. The overall burden is one that impacts more on low and emerging economies. Malnutrition during pregnancy and the early years development leads to stunted physical and cognitive development, increased susceptibility to diseases, and reduced productivity and economic opportunities. Women and children bear the brunt of food insecurity, with women being more likely to be affected by hunger than men and 144 million children under the age of five being stunted (too short for their age) due to chronic undernutrition.

While one in nine people in the world are undernourished there are regional disparities, Africa has the highest prevalence of undernourishment, with over 250 million people (19% of the population) suffering from hunger, within Africa emerging economies such as South Africa are experiencing rising levels of obesity alongside hunger. Asia follows closely with over 500 million people (11.4% of the population) facing food insecurity. In contrast, Latin America and the Caribbean have the lowest prevalence of undernourishment, with 9.5% of the population affected. High-income economies such as the UK and the US -have seen increased levels of food insecurity driving by changing economic circumstances. The nature of food insecurity in high-income countries is different from that in low and middle-income income but nonetheless damaging in its impact. It is more likely to be characterised by the consumption of highly processed foods high in calories, fat, salt and sugar interspersed with periods of hunger.

The UN estimates that by 2050, climate change will push an additional 100 million people into poverty and increase the number of undernourished by 20%. Conflict and political instability play a large part in food insecurity. The World Food Programme reports that 60% of the world’s hungry live in countries affected by conflict. This is a major challenge in countries such as Yemen, South Sudan, and Syria, where ongoing conflicts have contributed to food insecurity and malnutrition. Such conflicts and lack of global food governance can be further impacted by natural disasters and global events outside the control of national governments. The recent floods in Libya acerbated an already precarious situation, with only 1% of the land suitable for growing of grains resulting in a heavy reliance on imports. Adding to all of this was the war in Ukraine which resulted in less grain being available for export to Libya either directly or through the World Food Programme. Libya, since 2011, has had periodic wheat and cereals supply disruptions, shortages driven by speculative trading on global markets and higher local prices due to currency devaluation. Seventy-five per cent of the world’s poor live in rural areas, with many facing increasing challenges such as limited access to land, water, and other resources. They may live next to where food is grown but not have physical access to land and lack sufficient income to buy food.

Despite these alarming statistics, there have been some improvements in global food security, the prevalence of undernourishment decreased from 23.3% in 1990-1992 to 8.9% in 2019. The COVID-19 pandemic saw some of these advances being reversed, demonstrating the fragility of the global food system and the need for continued efforts to address food insecurity and malnutrition. The pandemic provided us with lots of initiatives by governments, civil society and the food industry to tackle the issue of supply, examples of these are included in our edited handbook (Caraher, Coveney & Chopra, 2023). Despite this the contribution of both governments and the private sector to the SDGs is not encouraging. WHO, FAO and other United Nations agencies are predicting an increase in food insecurity in 2024. Among the reasons for this are a lack of actions to meet the targets set by the Sustainable Development Goals (SDGs) and the Global Nutrition Targets (GNTs). Only 15% of the SDG targets are on track to be met by 2030 and the GNTs date for achievement, previously 2025, have been extended to 2030. Figure 1, shows that ranked by their contribution to each of the 17 SDG goals, global companies fell mostly in the middle with 38% aligned and 55% misaligned or neutral in their commitment and only 0.2% of companies strongly aligned to meeting the SDGs. The most strongly aligned goal was ‘Responsible Production and Consumption’, indicating a commitment, often under a CSR banner(Neufeld, 2021).

Figure 1 Source Neufeld (2021)

A key issue highlighted by many studies, including those in our edited volume, is the importance of cash transfers to families to address food insecurity, in the post pandemic era these are gradually being abandoned by governments using the excuse of austerity.

Conclusions

The COVID-19 pandemic and the subsequent lockdowns were not about always about food per se in terms of its amount and production but the pandemic had impacts on the food chain and the ability and resources to source food. This raises the need to plan for disruptions in the food supply chain as a fallout from other crises such as floods, conflict or trade wars. Amartya Sen noted, famines are not conditional on a lack of food or its not being available, but on how the entitlement to access is conceived (Sen, 1981). Food security at the household level can be influenced by skills, resources and lack of money or physical access to food; however, it is often not about an overall shortage of food within a community or society but about access. Within late-capitalist societies, access is often defined by consumerist models of access rather than a right to food.

There is a lack of action by the corporate sector in relation to addressing the SDGs and the GNTs, the global food and health agencies have little power to ensure compliance or to regulate the situation. These gaps need to be addressed as matters of urgency. The issues of global governance and regulation need to be revisited by food policy and food insecurity researchers. For example there has been little research on how to regulate global speculation around food and concentrations in the food chain this despite the issues being (Clapp, 2021).

References

Caraher, M., Coveney, J. & Chopra, M. (eds) 2023,  Handbook of Food Security and Society, Elgar, Cheltenham, UK.

Clapp 2021, “The problem with growing corporate concentration and power in the global food system”, Nature food, vol. 2, no. 6, pp. 404-408.

Neufeld, D. 2021, March 16th-last update, UN Sustainable Development Goals: How Companies Stack Up,.

Sen, A. 1981, Poverty and Famines, Oxford University Press, Oxford.

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By Salewa Olawoye, York University, Toronto, Canada

Growing up, there was a popular Nigerian television show called “Tales by Moonlight”. It gave stories from an African perspective that provided lessons, especially moral lessons, to the listeners. In recent times, the world experienced a pandemic that has opened up various opportunities of lessons for the world to learn. The recent global pandemic, Covid-19, changed the world in a lot of ways. Countries experienced extended preventative measures such as lockdowns that were thought to last for 2 weeks and every part of the society was affected. The pandemic ushered in an era of people getting sick, some others dying, many losing their jobs or working from home, businesses folding up and a general feeling of gloom and despair. Economic effects include supply interruptions through a reduction in hours worked and supply chains were affected, which influenced inflation. As a result of these and other Covid related issues, life as we knew it changed.

The effects of this global pandemic on developing nations differed yet the severity of the situation was not lost on many countries. It did not matter if they had proper health systems or not, the world felt the effects of Covid-19 and systems had to be adjusted to survive the pandemic. In the developing world, there was a general feeling of fear and doom as the devastating effects of Covid-19 in the world were publicized. In a CNN interview, Melinda Gates talked about Covid-19 being devastating in developing countries with bodies being littered around, and predicted catastrophic effects in countries in Africa. The continent was expected to produce the most devastating casualties of Covid-19 in the world.

Despite these predictions, countries in Africa survived the pandemic much to the surprise of the rest of the world. It almost seemed like can anything good come out of Africa? While the rest of the world embraced her entertainment (the music and movies) on social media, everything else seemed to be shown in a negative light during the pandemic. However, African countries survived the pandemic and a lot of the ways of survival need to be studied along with the survival strategies of the rest of the world. Countries in Africa provide a great case study because each country is different in terms of development, structures and systems. While non-pharmaceutical Covid-19 preventive measures such as lockdowns to flatten the curve were easier in countries with a more developed system like South Africa, others like Nigeria had to reopen before flattening the curve as for quite a number of people who depended on daily physical work to survive, hunger was a bigger pandemic than Covid-19. In all countries, monetary and fiscal policies were used to regulate the economy from the various effects of Covid-19.

In studying monetary policies around the world, it is quite common to focus on the West. If this study is focusing on developing countries, a heavy focus is placed on Latin American countries and Asian countries. African countries are largely underemphasized. When studied, the complexities in African countries and different structures that exist in them are often ignored. However, these complexities and differences make African countries an interest study in the fight against Covid-19. Using Sub-Saharan Africa as a monetary policy case study, we see that countries in Africa have different monetary regimes. Some countries have independent central banks while others belong to one of two monetary authorities, the Central Bank of West African States (BCEAO) or the Bank of Central African States (BEAC). Our book, Covid-19 and the Response of Central Banks: Coping with Challenges in Sub-Saharan Africa, captures these differences in African countries and how various countries adopt various forms of monetary policy to suit issues in a country and the country specific effects of these policies adopted. To achieve this, eight Sub-Saharan African countries are analyzed. They include Nigeria, Cote d’Ivoire, Ghana, Senegal, the Republic of Congo (Congo-Brazaville), Cameroon, Sierra Leone and the Democratic Republic of Congo (Congo-Kinshasha).

It is not uncommon to hear the statement “Africa is not a country” used to highlight the various countries and their differences within the continent. This book further fuels this stance through the study of Covid-19 and monetary policy in Sub-Saharan Africa. It highlights the different monetary policies and their effects based on whether countries have an independent monetary authority or if a country belongs to a monetary union. From a central banking perspective, we see how different systems produce different outcome and how these different countries in Africa tackled the challenges that came with Covid-19. We see lessons from African countries for Africa and the world.

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Ananish Chaudhuri

Ananish Chaudhuri is the author of “Nudged into lockdown? Behavioral Economics, Uncertainty and Covid-19” published by Edward Elgar Publishing.

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