Rituals of Care

Karmic Politics in an Aging Thailand

Felicity Aulino

• Publisher: Cornell University Press
• Year: 2019
• Print ISBN: 9781501739736, 9781501739729
• eBook ISBN: 9781501739750
• Topic: Social Sciences
• Subtopic: Buddhism
• Index: Social Sciences

Aulino's work is a strong contribution to the study of aging in the field of medical anthropology specifically because of the focus on the embodied performativity of care evident in her research practice and analysis. Rituals of Care is an excellent book, which offers a thoughtful approach to everyday care in Thailand. ? Anthropology & Aging

End-of-life issues are increasingly central to discussions within medical anthropology, the anthropology of political action, and the study of Buddhist philosophy and practice. Felicity Aulino's Rituals of Care speaks directly to these important anthropological and existential conversations. Against the backdrop of global population aging and increased attention to care for the elderly, both personal and professional, Aulino challenges common presumptions about the universal nature of "caring." The way she examines particular sets of emotional and practical ways of being with people, and their specific historical lineages, allows Aulino to show an inseparable link between forms of social organization and forms of care.

Unlike most accounts of the quotidian concerns of providing care in a rapidly aging society, Rituals of Care brings attention to corporeal processes. Moving from vivid descriptions of the embodied routines at the heart of home caregiving to depictions of care practices in more general ways—care for one's group, care of the polity—it develops the argument that religious, social, and political structures are embodied, through habituated action, in practices of providing for others. Under the watchful treatment of Aulino, care becomes a powerful foil for understanding recent political turmoil and structural change in Thailand, proving embodied practice to be a vital vantage point for phenomenological and political analyses alike.

1

THE KARMA OF CARE

Ordinary Actions and Their Consequences

Ek appears at the top of the landing and gingerly descends the polished wood steps, his broad shoulders and back straight as he balances the small frame of his eighty-five-year-old mother-in-law, who lies, wrapped in a Chinese-style red satin blanket, draped over his arms. He passes quickly through his wife’s sewing shop, which occupies the first floor of their three-story Chiang Mai shop house, through the glass door façade, and down to the pickup truck out front. Pillows line the flatbed of the old vehicle, waiting to take the old woman to her scheduled appointment at the district hospital. Ek exchanges a few jokes, heavy with political undertones, with his brother-in-law as their wives make a few final adjustments to the makeshift traveling bed. There is a brief reconfirmation of the trip’s expected timeline (8 p.m. return if everything goes smoothly, much later if a blood transfusion is required). Room is made in the cab for the anthropologist tagging along. And then the monthly caravan is off, the old woman in the back with one of her daughters and her daughter-in-law, her eldest son at the wheel.

What do Aom, the old woman’s eldest daughter, and Ek, Aom’s husband, do while the others are gone? Aom sits back down to her sewing table, Ek heads back out to his garden plot, or they spend some time with their thirteen-year-old daughter, Nok, enjoying the now rare time they have as a nuclear family alone. Do they cherish this time? Do they feel a relief as the truck pulls away and leaves them without the immediate burden of care for these short hours? I am left only to imagine, for my questions later will most often be met with laughter and vague answers about how it is they continue with everyday work.

Certainly, there is always work to do. It seems never to end. Aom and her sister Ying are up every morning at daybreak. Soon they will sweep the house from top to bottom, spray and wipe the front glass, clean the stoop, water the plants, do the laundry, and begin lunch preparations. But, first, the faucets must be turned on, allowing water up to the second floor bathroom, where buckets are prepared for their mother’s morning bath. There, on a low wooden platform on the far left side of the room, their mother has lain, save for the monthly trips to the hospital, for nearly three years.

The room is sparsely furnished—the bed, a log table with four wooden benches crowded around it by the window facing the street, a desktop computer on the far right by the stairs, and a glass wardrobe with samples of Aom’s fashionable creations from earlier in her career as a seamstress. The motor of the air mattress provides a constant hum day and night, sometimes accompanied by syncopated rhythms from the overhead fans. The center of the room is empty, providing space for the tables, supply bins, and buckets brought to the old woman’s bedside four times a day, as well as space for Ying’s bedding each night.

When Tatsanii—also known as Yāi or Khun Yāi, meaning grandmother—first became ill, the room was filled. Aom, Ying, their younger sister Kannikar, Kannikar’s two young children, and several aunts and cousins all made their bed around the family’s matriarch. The air was jovial, and the gathered women spent the nights talking and often laughing, sharing the new tasks of caregiving and the merit gained by such work. They were perhaps all waiting for the anticipated, the inevitable, the passing of the beloved elder.

The story is a familiar one in Northern Thailand, as elsewhere. Tatsanii was a talkative eighty-three-year-old, involved in her neighborhood and busy keeping tabs on her ten children and running the family compound with her husband. One morning, she fell and began convulsing. The family rushed her to the hospital. As her body contorted, her right side bending at the knee, wrist, and elbow, the medical staff sent a tube down her nose to provide her nutrients. After she had spent weeks as an in-patient, the medical team packed her up and, with some instructions for her daughters, sent her home. Ek generously offered to lodge Tatsanii on the second floor of their home, a modern concrete dwelling built next to Tatsanii’s old wooden house on the urban outskirts of the Chiang Mai municipal area. So there she went, and there she stayed. And stayed.

When I first met her family, Tatsanii had already been in a coma for over two years, fitted with a feeding tube, permanently bent at the knees and elbows, requiring a host of interventions each day.¹ The tasks are formidable, though Aom and Ying have gotten quite efficient over the years. In the early days, the basic routine—bathing, diapering, turning, propping, stretching, powdering, massaging, medicating, feeding, and so on—took three hours to complete. Now it takes the pair one hour to finish: one hour, that is, four times a day. And that does not include the laundry, the meal preparation, the house cleaning, the monthly trips to the hospital, Aom’s work as a seamstress and mother, and all the unexpected bits of daily life that intervene.

With Ying and Aom as guides, in this chapter I provide a phenomenological account of the everyday tasks of long-term caregiving in Northern Thailand. That is, I attempt to give a sense of how people experience the circumstances described. As noted in the introduction, the phenomenological orientation of this book is geared toward the social training of perceptual awareness and the lived experience that results from such attention to the world. Here I bring attention, first, to habituated physical procedures: what is done day in and day out. I then show how the karmic framework in which these routines are ensconced allows us to productively understand physical care acts in terms of ritual: repetitive practices that achieve effects through their correct performance, rather than through internal orientation to the tasks. Ideal internal orientation (in the form of equanimity) and the moral salience of intentionality are the focus of chapter 2, in which I explore the philosophical tenets of the Abhidhamma and its emphasis on abandoning or refraining from, rather than cultivating, particular mind-sets. But here, to escape the pull of the dominant analysis of self-cultivation in the Western tradition, I emphasize the physical and show how awareness is trained on and with physical action. The details of embodied practice help bring to the fore what counts in context as providing for others. In turn, the “rituals of care” presented in this case upset common presumptions about the psychological correlates of care dominant in the Western tradition.

Care in the Field

What exactly happens, on the ground, in caregiving situations? How do caregivers conceive of their roles and take to their tasks? What is at stake for people as their everyday lives are reoriented by caregiving? How do people meet the often conflicting demands on their time and identity in the face of providing care full time? To answer these questions, I turn to Aom and Ying as examples of the many people—mostly daughters and wives, but also sons and in-laws and various next of kin—who perform the duties of family caregiving for their elders in a rapidly aging Thai society.² Their lived experience provides a critical contribution to our current assessments of care.

The term “care”—in the literature of nursing, medicine, philosophy, feminist ethics, and the like—generally hinges on an understanding of “caring” as an internal conviction, a presence of mind and body that is attuned to the needs of others. In this way, care is but one part of medicine’s “dual discourse,” the other part being competence (Good 1995; Good and Good 1993). By extension, people are thought to enact true or ideal caregiving when they attend to physical and emotional needs with (or because of) empathy, bringing about a communion meaningful to all parties involved. Thus analysts distinguish between “technicians” and “practitioners,” the former being professional caregivers who fail to bring appropriate attentiveness and sincerity to their craft (Benner 1994, 58). Robert Bellah (1994) casts such a division as a “crisis” in the US health-care system, one whose deleterious effects require a great deal of energy to counteract.

But is this conception of “caring” a universal way of understanding the role and experience of the caregiver? Or are there particular sets of emotional and practical ways of being with people, ways with specific historical lineages, that can be differentiated as care in various contexts? I affirm different modes of care, and this chapter begins the unraveling of the lineages operating in the Northern Thai context that underlie not only processes of care but also more general understandings of the self, subjectivity, morality, and social dynamics.

Although anthropologists have long been interested in care-related topics—from the culture of biomedicine to the invisibility of home-care work, from humanitarian intervention to indigenous healing practices—it is increasingly clear that care itself has been undertheorized. Medical anthropologists have recently renewed attention to care and created space for a more comprehensive discussion.³ But all too often, anthropological work glosses over embodied practices, prioritizing other analytic concerns—such as emerging technologies of the self and subject formation, health-care professionalization, and social welfare reform—or simply transforming the mundane into something considered worthy of inquiry.⁴ And although there are important exceptions,⁵ ethnographic inquiry into embodied care practices outside European, North American, or predominantly Christian contexts is limited.⁶ Perhaps as a result, many analyses overdetermine the concept of care—particularly in relation to the often implicit connection that authors make between distinct inner states, among them beliefs and intentions, on the one hand, and outward actions and expressions, on the other. To unlock care’s potential as an object of study, it is necessary to revisit these analyses’ assumptions, which are evident in their emphases.

Take the emphasis on ethical reflections as a window onto the moral aspects of care.⁷ Julie Livingston and Arthur Kleinman, for example, both demonstrate how caregiving is a profoundly “humanizing” moral act, but their reliance on ethical explanations and justifications obscures the insight, from the anthropology of morality, that the mainstay of ethical life lies in habituated activity.⁸ Livingston (2012) powerfully argues that nurses in a Botswana cancer ward rehumanize their patients by normalizing physical conditions that elicit disgust in others. Yet she does not fully distinguish the habituated care routines that allow these nurses to act in such a manner from the nurses’ Christian-inflected ethical claims about their behavior; in turn, context-specific orientations to care work become naturalized as part and parcel of rote action.⁹ Similarly, while Kleinman’s “notion of a divided self with hidden values” (2011, 805) provides a vital rallying cry for self-reflection in biomedical caregiving, such an evocation of care in other contexts may too quickly map a presumed set of universal orientations to care onto what Michel Foucault (1988) traced as a specifically modern Christian hermeneutics of the self.

Another emphasis in ethnographies of care has been the irreducibility of care to economic considerations. Such work seeks to maintain a distinct relational space for care, even while acknowledging the effects of economic pressures and sociopolitical conditions on the working conditions of care. This emphasis could establish a more robust understanding of care in practice, but, I would argue, only if combined with attention to ordinary embodied experience. Upholding a simple opposition between care and commodity leaves open the possibility of misprescribing particular emotional or cognitive components as if they were intrinsic to the category of care universally (Zelizer 2010). Even if we maintain, following João Biehl (2012), that care is not a commodifiable or technological intervention but a “relational practice,” we still need to investigate how people constitute such relational practices across contexts.

Studies of the political uses of care show a similar propensity. Following suit, one could argue that the political logics of long-term care mirror those of humanitarian discourse as a whole—insofar as caregivers are cast as victims, erasing the political and economic causes of their suffering and requiring particular performances of distress for aid (Fassin 2012b; Ticktin 2011). But for such an account, the underlying orientation and practical daily affairs of such “victims” need barely surface. Paying close attention to people’s embodied experience, like that of Aom and Ying, could reinfuse political and economic analyses with a sense of what is changed and what is lost sight of in the wake of social and economic reform aimed specifically at care.

In short, the scholarship on care currently misses the possibility that care can be separated from particular psychological states and correct intentions, and can in turn be productively understood in terms of physical practice or, as I argue, as ritual. Conceptualizing care as ritual allows us to get beyond meaning-centered approaches that presume that physical acts and core sincerity are aligned in cases of “real care,” and to concentrate on what counts most in context.¹⁰ Moreover, it allows us to pay attention to what caregivers do rather than just what they say they do, substantiating moral life as lived. And it brings us closer to the heart of anthropology, where discursive analysis is less important than “being there” (Borneman and Hammoudi 2009). Just as Talal Asad (1993) brought attention to the importance of practice over the uncritical privileging of a narrow conception of belief in religious studies, so too should we call on care studies to delve more fully into embodied routines.¹¹ In doing so, we can productively explore care as habituated action separated from internal orientation, at least provisionally, to bring a wider range of human experience into view.

Many factors—including economic status, profession, family and community makeup, accessibility of health care, and so forth—contribute to the composition and duration of the daily tasks I describe in the pages that follow. Aom and Ying are neither desperately poor nor solidly middle class. They represent a demographic in decline—those with a large sibling base to share the physical and financial responsibilities of caring for their mother. Aom’s home-based business and Ying’s unemployment make their physical care more reliable than that of people who work outside the home or cannot support an unemployed household member. People who are better off often employ help or stop working to free up caregiving time; those without such resources often cut corners in care or fall into more difficult circumstances as a result of maintaining home responsibilities. The Thai universal care plan has in recent years broadened health-care access nationally, but without all-encompassing provisions for home aides, it does littl...

Table of contents

• Acknowledgments
• Note on Names and Thai Transliteration
• Introduction
• 1. The Karma of Care
• 2. The Conditioning of Care
• 3. The Subjects of Care
• 4. The Civic Landscape of Care
• 5. The Violence of Care
• Conclusion
• Notes
• References
• Index