WSIF-01743; No of Pages 10

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Women's Studies International Forum

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Care worker migration, global health equity, and ethical

place-making
Lisa Eckenwiler
Department of Philosophy, George Mason University, United States
Department of Health Administration and Policy, George Mason University, United States

a r t i c l e

i n f o

Available online xxxx

s y n o p s i s
The division of care labor has long been gendered; it is increasingly transnational. Part of the
feminization of international migration, many women seek employment abroad as nurses, nurses'
aides, and home care workers. This gendered migration generates serious concerns of injustice,
chief among them the deepening of global health inequities in source countries and injustices
against migrant care workers. Here, I assume that governments and other agents whose policies
and practices cross borders share responsibilities for addressing injustices, grounding these
responsibilities in our nature as ecological subjects. This conception of persons directs attention
to our embeddedness socially and also spatially, in geographically identifiable locations which are
also constituted relationally. Responsibility for addressing injustices, in turn, might fruitfully be
conceived as ethical place-making. Here I define the notion of ethical place-making and examine
its potential to generate ethically urgent social change in both source and destination countries
and their care settings.
2014 Elsevier Ltd. All rights reserved.

Introduction
The flow of women from low- and middle-income countries
seeking employment in the health care especially long-term
care sectors of affluent ones generates serious concerns of
injustice, chief among them the deepening of global health
inequities in so-called source countries and injustices against
these migrant workers. Whether governments and other agents
whose policies and practices cross borders, such as international
lending bodies, have obligations to address injustices continues
to be debated. Those who argue affirmatively offer various bases
for them, including shared humanity, benevolence, and complicity in harms suffered.
In this paper I assume that there are responsibilities
for addressing injustices, yet provide an alternate account of
their grounding. Elsewhere I have argued that responsibilities
for global justice, in particular global health equity, lie in a
conception of subjects that emphasizes our relational nature,
and that also directs attention to our embeddedness spatially,
in geographically identifiable locations (Eckenwiler, 2012).

The meaning and significance of our implacement remain

undertheorized in accounts of global justice generally and of
health equity specifically, as well as in feminist ontologies
and theories of justice. Responsibility for health equity, I've
suggested, might fruitfully be conceived in terms of ethical
place-making. Here I will discuss how the notion of ethical
place-making has the potential to generate ethically urgent,
justice-promoting social change in both source and destination
countries.
The paper proceeds as follows: I first offer a brief
overview of the contemporary phase of nurse and care
worker migration and discuss its implications for global
health equity and for workers' autonomy and equity. Next, I
present the argument that responsibilities are grounded in a
particular relational ontology, one that highlights our social
embeddedness and our spatial implacement, and the intersubjectivities of identities and place. From there, I define the
notion of ethical place-making for health specifically, providing a preliminary sketch of its key elements. Finally I explore
how social change, in the form of ethical place-making, can

http://dx.doi.org/10.1016/j.wsif.2014.04.003
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Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

be made manifest in care settings of source as well as

destination countries.
The analysis here centers on the migration of two
distinct yet often-overlapping groups of health care workers:
nurses, regarded as skilled health professionals, and other
unskilled paraprofessionals such as nurse aides, home care
aides, and personal care assistants, known by various names
in various countries. I should say at the outset that these
distinctions are problematic and should be re-conceptualized
given their discounting of the considerable and complex set
of skills required for any care work and, in turn, distorted
assessment of its value. More specifically, I consider those
who move from low- and middle-income countries and
find employment in the United States' long-term care sector
(Browne & Braun, 2008; Martin, Lowell, Gozdziak, Bump, &
Breeding, 2009). The burgeoning aging population, and in
high-income countries, growing demands and expectations for
affordable, quality long-term care services, create abundant
opportunity in this niche of the increasingly-globalized care
labor market (OECD, 2005). Home care, for instance, is among
the fastest growing occupations in the US and is expanding
rapidly in other parts of the world (Paraprofessional Health
Institute, 2010). Particularly problematic about this most
recent surge is the growing share moving from low-income
countries with high disease burdens, more rapidly growing
elderly populations, and fewer available resources to wealthier,
healthier ones (Polsky, Ross, Brush, & Sochalski, 2007; WHO,
2006). This sort of asymmetry characterizes the relationship
between the US and the main countries that serve it: the
Philippines, countries of the Caribbean, including Haiti and
Jamaica, and India (Martin et al., 2009).
There are a number of important differences between
skilled health professionals and unskilled health workers,
including their education and training, typical immigration
pathways and status, and overall experience as migrants.
While I highlight key differences between them at times, at
some risk of obscuring what may be morally relevant
particularities I combine them for the most part here. This
is justified for a few reasons. First, a great many migrants
who have trained as registered nurses fill positions in
long-term care for which they are overqualified (OECD,
2011). It is unclear but it may be that this de-skilling or
down-skilling occurs more often in long-term care because
this labor sector suffers from some of the worst recruitment
and retention problems and in turn, unoccupied positions
in any health care field (Institute of Medicine, 2008). Too,
numbers of people who qualify as nurses in source countries
are likely underestimated because their qualifications are not
necessarily recognized by destination countries at least not
straightaway even though they are employed. Moreover, the
working conditions in long-term care are so poor overall that
there seems to be more overlap in the experiences of skilled
and unskilled migrant workers here than in other health care
sectors (OECD, 2011; Spencer, Martin, Bourgeault, & Eamon,
2010). Home care, which employs a significant share of
foreign-educated nurses (Martin et al., 2009), is especially
ill-reputed both generally and with respect to migrant care
providers for reasons I describe below. Finally, to the extent
that temporary work visas are on the rise, concerns related to
impermanence are increasingly salient for both groups, not
only the allegedly unskilled (Spencer et al., 2010).

Care worker migration and global injustice

Cited as one of the most pressing issues of our times
(Chatterjee, 2011: 456), health worker migration now occurs
at unprecedented rates. This form of labor migration has a
long history and comes in many forms, but the transnational
flow especially from low and middle-income countries to
wealthier ones, known as asymmetrical migration has
never been higher (Dumont & Zurn, 2007). In keeping
with a broader trend toward the feminization of migration
(Dumont, Martin, & Spielvogel, 2007; Ghosh, 2009), women
pursuing employment as nurses and other health care
workers, such as nurse aides and home health aides, have
come to be an integral part of the global economy (Kingma,
2006; OECD, 2011). The United States stands out as the
largest importer, and the only net receiver (OECD, 2008).
Several things align to encourage the movement of these
women across borders. Colonialism and its legacies of interdependence have contributed to transnational health worker
production and exchange (Raghuram, 2009: 30). United States
missionary and military involvement in the Philippines, along
with targeted foreign policy strategies, began fueling the
mobility of Filipino nurses over a century ago (Brush, 1995;
Choy, 2003). Similarly, the modern-day migration of Indian
nurses can trace its roots back to the British Empire's Colonial
Nursing Association (Rafferty, 2005).
The contemporary flow may be most attributable to
economic re-structuring by international financial institutions
of economies and public institutions in low- and middle-income
countries, which has generated job losses in many sectors,
including health care (Buchan, Parkin, & Sochalski, 2003). More
recently, the IMF's demand for ceilings on public wage
spending has thwarted efforts to hire needed health workers
and educators, even when funds are available (Schrecker, 2008).
The crafting of global trade policies (specifically the Global
Agreement on Trade in Services, or GATS) to allow for the
commodification and trading of care services on the global
market is a further factor (Connell, 2010).
At the same time, certain countries, like the Philippines and
India, have built elaborate social and institutional structures to
facilitate the training and export of their own citizens with
the hope that remittances will help to reduce the burden of
debt and poverty (World Bank, 2005). Government-supported
educational institutions educate and train nurses and other
care workers here primarily for foreign and more affluent
markets in Saudi Arabia, the US, and the United Kingdom
(International Labour Organization, 2006; Lorenzo, Galvez-Tan,
Icamina, & Javier, 2007). In this context, a highly profitable
transnational recruitment industry, involved in a range of
activities related to recruitment, testing, credentialing, and
immigration, is flourishing (Connell & Stilwell, 2006; Pittman,
Folsom, Bass, & Leonhardy, 2007).
Immigration policies also play a prominent role in shaping
care worker migration. Selective immigration, especially for
skilled workers and workers in areas with shortages, like
nursing, is an essential instrument of industrial policy under
globalization (Ahmad, 2005). Health and long-term care
industry organizations in high-income countries, which regard
international recruitment as a way to address shortages and
reduce hiring costs and improve retention, persistently lobby
for the easing of immigration requirements in order to gain

Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

access to nurses and other skilled health care workers (Buchan

et al., 2003; Pittman et al., 2007). Less skilled workers are not so
sought-after, but play an increasingly prominent role in the
global care labor force. Increasing demand and a lack of legal
avenues contributes to the illegal immigration of many women
who end up working in long-term care, especially in the
growing informal or gray economy in home care (Martin et
al., 2009; OECD, 2011).
Destination countries' care regimes, including their health
policies, also intersect with economic, immigration, and labor
policies to influence the demand, employment, and treatment
of migrant workers. Especially notable is that governments
more and more are formulating immigration policies and
structuring provisions for the care of children, the ill, and the
elderly in coordinated (as opposed to haphazard) ways for the
sake of cost savings (Williams & Brenna, 2012). Nevertheless,
in most places, including the US, it has been the absence of
comprehensive and coordinated long-term care policy that
contributes to the current unprecedented reliance on migrant
care workers. Workforce planning for the demographic shift
has been weak, especially in long-term care. Poor working
conditions (by high-income country standards), and the
longstanding failure to address them, exacerbate persistent
recruitment and retention problems, which in turn, helps to
draw workers from abroad (Institute of Medicine, 2008;
Spencer et al., 2010).
Even as the provision of public care has been limited,
comparatively, in the US, trends are toward greater public
disinvestment, privatization and informalization of care
provision. This means the use of for-profit providers who
compete for contracts and de-centralized care, and decision
and accountability structures. It involves the growing use of
mechanisms like cash allowances for care that shift responsibilities for finding and coordinating care to families and
consumers. Like many once strong welfare states in Europe
(Williams & Brenna, 2012), the US is restructuring the nature of
state support available, shaping the market for migrants, and
setting the conditions for their work, as well as for the elderly's
care (and for family caregivers' lives). While this is beyond the
scope of the analysis here, it is worth noting that research in
other countries finds that marketization increases inequalities
among users of care services, because of differences in their
capacities to act effectively as consumers of care and also
because private providers are increasingly successful in lowering regulatory standards in order to maximize profits.
Two further factors involve care policy (what Fiona Williams
calls generally care regimes). First, the unavailability for most
family caregivers in the US who are employed in the labor force
of paid leave and other forms of support (Williams & Boushey,
2010) is a likely contributor to care worker migration. Analyses
done in other countries demonstrate that these and other
paid caregivers fill a growing care gap, a gap created partly of
course by shrinking family sizes, geographic dispersion, and the
presence of women who would have been caregiving in the paid
labor force, but also by shrinking public care infrastructure and
weak workplace leave policies. This works in conjunction,
finally, with a social norm that conceives of care as largely a
family's principally woman's private responsibility, not a
matter for public concern.
This migration generates a complex configuration of
ethical issues. I focus on only two: the deepening of global

health inequities in source countries and injustices against

migrant care workers.
Global health inequities
There is now overwhelming consensus that when health
workers leave, population health erodes. According to the
World Health Organization (2006), fifty-seven countries face
severe health worker shortages. These shortages affect both
the quantity and the quality of health services available and
provided. They worsen inequalities, for example, in infant,
child and maternal health, vaccine coverage, response
capacity for outbreaks and conflict, and mental health care.
They lead to striking patienthealth care worker ratios
(especially in rural and remote areas), hospital, clinic, and
program closures, and an increased workload, stress and
fatigue for remaining health care workers (Chen et al., 2004;
Mdecins sans Frontires, 2007). There is significant variation among countries when it comes to the impact of this
migration, depending upon such factors as size of the
country, its geography and demographic make-up, disease
burden, stock of trained workers, educational infrastructure,
and so on. People in source countries, all told, may get less
care than they once did, may receive it from someone with
less education and training than would be the case but for
migrations, and people who formerly received care may get
none at all. In some source countries, the absence of health
care workers has caused a virtual collapse of health services
(Packer, Labont, & Runnels, 2009: 214). Recent evidence
finds, moreover, that the adverse effects of losing health
workers are not compensated by remittances, for they do
not contribute to the development of health systems, care
provision, or compensate for economic losses of educated
workers (Packer, Runnels, & Labont, 2010). Low-income
countries' investment in education and training for health
care workers who ultimately leave, say some critics, reflects a
perverse subsidy (Mackintosh, Mensah, Henry, & Rowson,
2006). The Philippines, for example, the largest source of
registered nurses working overseas and of long-term care
workers in the US, has become a training ground (Ball, 2004:
340) for the health care systems of wealthier countries, while
its own health care system is depleted. India, another primary
source country used to help stock the US long-term care
workforce, is also reforming nursing schools around international standards and the needs of importing countries. There,
supported by the government in various ways, commercial
recruiters and hospitals participate in business process
outsourcing. Meanwhile, India has among the lowest nurseto-population ratios of all source countries and a rapidly aging
population (Khadria, 2007).
While most of the research done to date focuses on the
loss of skilled health care workers, physicians, and to a lesser
extent nurses, research that explores in detail the health
impact of losing other care workers is only just underway
(Bourgeault, Labonte, & Murphy, 2013a; Bourgeault, Labonte,
& Murphy, 2013b; Bourgeault, Labonte, & Murphy, 2013c).
Several variables complicate matters here. As noted above, a
number do in fact leave as skilled professionals but take jobs
categorized as unskilled for some period of time, while they
try to situate themselves as migrants. Another important
factor is the extent to which a given individual would be

Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

incorporated into the health care system in her home country

if she were to stay. This varies across countries and depends
on things like the country's economic condition and job
opportunity pool as well as the structure of health education,
which, as I pointed out earlier, is more and more likely to
revolve around the needs of markets abroad.
Having said this, all things considered, to the extent that
these workers are the principal providers of basic health
services as well as long-term and palliative care, their absence
may also prove extremely troubling for the health of low- and
middle-income countries (WHO, 2006). Their contribution
to family care work is also highly relevant, though often
underestimated in official accounts of the global health
workforce. And, indeed, as budgets and health care systems
become depleted or re-organized around global markets,
governments manage the care burden by shifting it to women
(often the family members of migrants) in private households
(Harper, Aboderin, & Ruchieva, 2008; Makina, 2009).
Autonomy and equity for migrant care workers
The implications for migrant care workers are also
significant. If we understand autonomy to mean something
like being relatively free to choose one's actions and course in
life from a decent set of options, and equity to mean
something like the absence of avoidable and unfair inequalities, the picture that emerges is complex, within and across
the categories of skilled professional and unskilled worker.
Threats to autonomy and equity for migrant care workers
come from several sources. To the extent that the global
migration of nurses and other care workers is fueled by
traditional gender norms and racial and cultural stereotypes
(Brush & Vaspurum, 2006; Schwenken & Eberhardt, 2008), it
constrains the imaginations and choices of women and girls to
varying degrees, depending upon their particular circumstances. At the same time, they especially those in countries
like the Philippines and India organized around exporting
workers are subject to nationalist, neoliberal rhetoric, which
can encourage them to organize their conduct around what is
by the lights of government officials and international lenders
most beneficial to states' economies (Lulle, this issue; Schild,
2007). These rhetorical strategies operate with a caring face,
suggesting that labor migrants, especially women, will enjoy
expanded opportunities for choice and prospects for equality.
Yet, by cultivating forms of subjectivity that are congruent
with capitalism in its latest phase (Schild, 2007: 199), and
enforcing expectations for individual responsibility for familial
and national well-being, creating narrow job pathways, and
perpetuating gender norms about care, they may very well
thwart autonomy and equity.
Most if not all migrant laborers are subject to
flexibilization, a rightly awkward term coined to capture
process[es] of self-constitution that reflect and perhaps
perpetuate given models of social organization (Fraser, 2009:
129). Its defining features are fluidity, provisionality, and a
temporal horizon of no long-term, experiences of a substantial
share of labor migrants at least for some period and often in
perpetuity. Transnational economic and other structures compel care workers to mobilize when most say they would rather
work at home (Van Eyck, 2004). There is also the de- or
down-skilling noted above (Alonso-Garbayo & Maben, 2009).

The rapid expansion of the informal, privatizing economy in

home care which, in the US, at least employs a large number of
registered nurses often providing unskilled care (Martin et al.,
2009), offers another example of flexibilization. More generally,
the tendency under neo-liberal economic policies to define
more and more jobs as temporary and unskilled, and issue more
temporary visas for migrants, adds to the contorting affect.
Inequities may persist under such schemes and choices may be
constrained.
Although countries often incentivize immigration for some
workers, countries differentially incorporate migrants when it
comes to immigration and citizenship status (Carens, 2008;
Kofman & Raghuram, 2006). Care workers, especially the
so-called unskilled, as many care workers are categorized,
often lack citizenship in the countries where they are employed
and therefore have a limited set of political rights and labor
protections (Bosniak, 2009; Dauvergne, 2009). Access to health
and social services may also be diminished or lacking altogether
(Deeb-Sossa & Mendez, 2008; Meghani & Eckenwiler, 2009).
Although many attain permanent status and live with their
loved ones in destination countries, many others live in
transnational families and engage in transnational care practices, participating in family relations and meeting obligations
across space and time (Doyle & Timonen, 2010; Parreas, 2005).
To the extent that identities and, indeed, capacities for moral
and other forms of agency are shaped by familial relationships
and engagement in the communities from which we come
(Mackenzie & Stolijar, 2000), migration may lead not just to
geographic and political displacement but a self-rupture
(Kittay, unpublished). Care workers, especially those who wish
to but cannot bring family, might be said to experience a sort of
bi-placement of identity, enduring the harm of never feeling
oneself as fully here (Kittay, unpublished; Hondagneu-Sotelo &
Avila, 1997). These moral harms faced by socially embedded yet
dispersed individuals can at the same time threaten the
relationships themselves; they may lead others to reinterpret
our social or moral standing [and] compromise thebonds
we have with them (Miller, 2009: 513).
There can be important gains for women, and in particular
those who come from oppressive circumstances, in income,
self-trust and confidence, household decision-making, as well
as in spatial mobility and freedom from restrictive gender
norms (Pessar, 2005; Percot, 2006). They may advance their
migration project (Ottonelli & Torresi, 2012). Many advance
their career goals, particularly skilled nurses. Depending upon a
range of factors, then, including level of education and training,
experience, place of employment and so on, care workers may
be vulnerable yet also become more autonomous and achieve
expanded opportunity (Straehle, 2013). Given their overall
position within the global economy and their concrete work
settings, their prospects for enhanced autonomy and equity
under current economic and political trends are, at best,
precarious (Barber, 2009; Ghosh, 2009; Robinson, 2011).
Grounding and assigning responsibilities of global justice
Theorizing interdependence
I have argued that deepening global health inequities and
injustices against migrant care laborers constitute structural
injustice (Eckenwiler, 2012). I follow Iris Marion Young here

Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

who defines this as the domination or deprivation of the

means to develop and exercise [one's] capacities, at the same
time as [my emphasis] these processes enable others to
dominate or have a wider range of opportunities for developing
and exercising their capacities (Young, 2006:114). I've also
argued that the dense and radically asymmetrical relations of
interdependence that connect people in high-income countries
to migrant care workers and populations in need of care in
source countries ground responsibilities for addressing it.
There are several ways to think about this interdependence. In the broadest terms, we might consider our shared
humanity. On a slightly more particularist view (O'Neill,
2000), an agent's moral obligation encompasses all those
people upon whom her own activities depend, and thus even
to the geographically distant. Another line of thought holds
that we are related through shaping and enforcing the social
conditions that foreseeably and avoidably cause the monumental suffering of global poverty (Pogge, 2005: 33), and
that motivates migration. Here our connection is a matter of
substantially contributing to upholding the institutions
responsible for injustice (Pogge, 2004: 137), in the case
here, those institutions facilitate the transnational division of
care labor. Closely related but more nuanced in its account of
interdependence and of how structural injustice unfurls is
the social connection model of responsibility in which [o]
bligations of justice arise between [agents] by virtue of the
social processes that connect them (Young, 2006: 102). All
agents, in other words, who contribute by their actions to
the structural processes that produce injustice have responsibilities to work to remedy these injustices (103).
As citizens of a democracy, people elect leaders who help to
establish the health, labor, and immigration policies that help
mobilize care workers from poor countries. These same citizens
support leaders who create and perpetuate the policies of
international financial institutions such as the World Bank and
the International Monetary Fund (IMF) and trade organizations
like the WTO. Then too, there are the demands and expectations of privileged people concerning care, which rest in part on
economic structures from which they have benefited, along
with certain social norms many families buy into. As Joan
Tronto (2006) points out, the pervasive tendency, particularly
among White middle and upper class families, to understand
caring as a matter involving the needs of their loved ones,
and to act according to what appears to be best for them
exclusively, can lead to moral hazards. In understanding caring
in such private terms as families are socially and economically compelled to do in the US they may not consider the
implications for those who support them or for their kith and
kin in less well off parts of the world. Such myopia constitutes,
in Tronto's words, privileged irresponsibility where this
creates or perpetuates injustice.
Reflection on the longstanding relationships between
source and destination countries, however, makes clear
another way of thinking about grounding responsibilities:
the global interdependence that increasingly characterizes
care work reveals the thoroughly relational nature of our
identities and habitats. While the accounts of justice
described above highlight interdependence under globalization, they obscure its significance for the cultivation and
sustenance of identities and, of the places in which they
emerge and dwell.

Identities are established and maintained inter-subjectively,

through care and dependency relations and interactions with
family members, friends, and others, including those who are not
our compatriots. The care provided by migrant workers
nannies, nurses, home care aides and so on in nurturing
children and sustaining the ill, the disabled, the elderly, and their
family members, has for some time been and is now an
increasingly integral part of who (we) the privileged are, that
is, how we become who are, persist in the manner we do, and
how we endure before dying as beneficiaries of care, members of
families, and citizens of an affluent country who participate in
and benefit from economic and labor policies that rely on
low-wage, unjustly treated workers. Places, too, are created and
shaped inter-subjectively (Raghuram, Madge, and Noxolo, 2009:
8), and should be understood as being, in part, constructed out
of a particular constellation of social relations, meeting and
weaving together at a particular locus. [E]ach place can be seen
as a particular, unique point of intersection (Massey, 1991:
28), its particularity being its set and configuration of relations,
and its position within a wider web of social relations. Like
subjects, because they are shaped by social interactions, places
have plural and shifting identities.1
Places have to meet certain conditions if we are to survive,
much less realize justice. The growing body of evidence
concerning societal determinants of health inequities makes
this abundantly clear (Marmot, 2007). Heightened exposure to
hazards (industrial and waste, and weak infrastructure), and
diminished access to resources of all kinds (food, health care,
parks and other public space, transportation) harm health.
People face increasing social isolation and depression, and
restricted mobility as a result of the configuration of the built
environment. And people ensconced in hospitals, clinics or
their remnants and homes with inadequate human and other
health resources are increasingly likely to languish and perish,
due to policies and practices of states, international bankers, and
the for-profit sector, and the (albeit also constrained) choices of
individuals in well-off parts of the world who fare far better.
We are only properly conceived, indeed, when we are
understood to be ecological subjects. Ecological subjects, as
Lorraine Code argues, are made by and making [our] relations
in reciprocity with other subjects and with(multiple, diverse) locations (Code, 2006: 128). [L]ocatedness and
interdependence are integral to [our] possibilities. Ecological
subjects cannot survive or thrive in the absence of effective
public health and health care systems, and care relations, and
they may struggle to do so when environments social,
institutional, and other are impoverished, constituted to
narrowly define their possibilities, and/or constrain their
abilities to meet their needs and the needs of their loved ones.
On the account I have offered, then, we are responsible for
addressing injustices not (merely) because of our humanity
and/or participation in processes that generate them, but also
because of who and what we are as ecological subjects:
creatures whose identities and dwelling places are not merely
relational, but intersubjectively and asymmetrically constructed
(Eckenwiler, 2012).
Assigning responsibilities
Typically in discussions of global justice, including
discussions of global health equity, states are assumed to

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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

have primary responsibility. Yet some states do not have the

capability to ensure justice, some lack the desire, and some
states with the desire to be just are rendered more porous by
neoliberal policies and programs and, so, are constrained in
their capacities by the activities of other agents operating
within them (O'Neill, 2004: 24647). International lending
bodies and transnational corporations may now have an even
greater influence on health in some parts of the world than
do governments or global health actors like the World
Health Organization (People's Health Movement, 2005).
Transnational corporations, non-governmental organizations, international lending bodies, and other global actors
and institutions should, therefore, serve along with states as
primary agents of justice. All, indeed, dwelling [my
emphasis] in this institutional and causal nexus, are
responsible (Young, 2000: 224). What, then, are they
responsible for doing?
Ethical place-making
I have argued that conceiving of persons as ecological
subjects grounds responsibilities to address the deepening
global health inequities and threats to autonomy and equity
that arise in the context of care worker migration. Contrary,
then, to the tenets of much liberal moral and political
philosophy, we should resist a reductive, de-contextualized
view of individuals as the units of moral and political
concern; we cannot properly be conceived apart from our
embededdness in social relations and in geographically,
atmospherically identifiable locations which are also partly
constituted through complex processes of interdependence.
Social and political responsibilities, on this view, might be
conceived as ethical place-making (Raghuram, Madge,
Noxolo, 2009: 7). Geographers are credited with coining the
phrase (Massey, 2004, 2006); I try to define it more fully, if
not yet satisfactorily. Here I offer a preliminary sketch of a
theory of place, for health and health equity in particular, and
a way of understanding place-making as a practice that can
undermine or enhance health equity.
Place is no fixed thing (Casey, 1997: 286). It can be
understood as being around us, but also in and with us. The
discussion above points to: institutional care settings, which
are also workplaces, such as hospitals and clinics (or their
remnants), private homes, classrooms, hubs and vehicles of
transportation, internet sites, bodies and psyches. It highlights transnational space: places of transition for nomads,
refugees, migrant workers such as borders and immigration
offices. It also makes clear the rhizomatic structure of
[our experience of] implacement (Casey, 1997: 337), or the
reality that our locatedness involves navigation between
interconnected places: homes, places of work, care settings,
borders, and so on. People suffer ill health as a result of social
structures and processes that create fragmentation or cause
rupture, as in lived experiences of segregation, movement
between fragmented care settings, movement from one's
place of employment to care settings, hypermobility, migration, and familial separation (Kelly, 2012).
The significance for health of where people are situated
amid social structures cannot be overstated (Marmot, 2007).
Economic status, gender, race and ethnicity, social connectivity,
and citizenship/immigration status figure in the development

and persistence of health inequalities. Even natural events

like heat waves, famines, and tsunamis, which occur in and
affect specific places and people most often the poor are, in
part, attributable to social practices and policy choices. Climate
change is an a especially compelling case of the significance of
geographical and social embeddedness for the health of
ecological subjects, for [t]he poor, the geographically vulnerable, the politically weak, and other disadvantaged groups will
be most affected (Marmot, 2007).
So what is ethical place making, in a given place or in the
interrelations between them? I propose that this ought to
include at least five elements: 1) freedom from foreseeable and
preventable threats to health, and equitable access to effective
health and other caregivers, including trained health personnel
and services capable of effectively meeting local population
health needs; 2) ecological integrity, understood in terms of the
built and natural environments; 3) the nurturance of relational
autonomy and capacities for transformational agency across the
life span; 4) inclusion, and parity in voice and participation; and
5) solidarity, or engagement in justice-centered work with
others, including those who may not be one's compatriots or
fellow group or community members, who may or may not
share in experiencing injustice.2 Each of these elements, a few
adapted from a theory of civic place (Jennings, unpublished),
and the relationship among them call for more elaboration. My
modest aim here is to begin to formulate criteria and argue that
ethical place-making for health equity calls for their cultivation
and sustenance. The specific targets of intervention are the
social processes and practices that threaten the essential
elements for ecological subjects in their particular habitats.
A few words are in order about how these ideas fit within the
larger conversation about justice. Contemporary work on justice
has shifted away from thinking strictly about the distribution of
resources, or what people have, toward their capacities, or, what
they are able to do and to be (Nussbaum, 2006: 70). What I will
call enabling conceptions of justice aim at attending to the
social and political conditions that support people's capacities for
self-development and self-determination. Iris Marion Young's
theory of justice as enablement calls for reform of the social and
institutional structures that systematically constrain people's
capacities for self-development and self-determination. Carol
Gould's notion of justice as equal positive freedom, requires
not only the absence of constraining conditions such as coercion
and oppression but also access to the means or conditions for
self-transformation and the development of capacities and
the realization of projects over time. Justice, here too, is about
the availability of enabling conditions. Finally, Nussbaum and
Sen's capability approach emphasizes people's capacities to be
and to do. As Nussbaum underscores, here active striving and
achievement matter (2006, 73).
As I conceive of it, ethical place-making fits within this
family of enabling accounts. The persistent emphasis on the
self in articulating the ideals of justice in these views,
however, serves to obscure our interdependence, need for
caring relations, and for fit with our environs.3 Liberal and
even some post-structural formulations of the self and its
telos risk not reckoning sufficiently with the extent to which
our capacities and our possible ends are shaped, that is
constrained and enabled, by intersubjectivity and by our
implacement not just corporeal and social but also
ecological. Moreover, in a global economic order marked by

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International Forum (2014), http://dx.doi.org/10.1016/j.wsif.2014.04.003

L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

the retraction of the public sector, rising inequality, and

dramatic effects of climate change, a discourse of selfdevelopment and self-determination, unless it rests on a
deeply social understanding of selves, should give us pause
given its potential to support the retraction of public
investment and infrastructure for care (in addition to its
careerist, competitive tenor).
In the final section I consider how the notion of ethical
place-making might help in the transformation of places of
care for the ill and elderly in source countries which are
also, of course, places of work for those who do not migrate
along with places of care employing migrant (and other
vulnerable) workers. Here I leave aside a discussion of ethical
place-making for the elderly themselves and focus on care
workers. It is an impressionistic portrait, in that I will not
offer finely grained policy and practice recommendations and
specific policy levers for specific countries. Nor will I discuss
the role and significance of each element in every recommendation here. My intent rather is to help begin the
conversation about how to understand and put to use the
norm of ethical place-making for health.
Source countries and their care settings
Ethical place-making calls, above all, for international
lending bodies to rescind the requirement on debtor countries
to cut public spending and contribute to re-building public
health systems dismantled under structural adjustment policies. This seems to be the most vital step in expanding
employment opportunities for nurses and other care workers
in hospitals, clinics, and health programs and, in turn, creating
more amply-resourced care settings. It would also enable those
care workers who remain in country to function in less
stressful, exhausting conditions. It would help to make private
homes, where women and girls now face greater burdens of
care for their family members and friends due to institutional
incapacities, places where they can better develop and exercise
their capacities for autonomous agency and do so under more
equitable conditions.
Some have argued that health education should be
tailored to meet a country's needs (Eyal & Hurst, 2008)
rather than an inflated international standard. Governments
in source countries, on this view, should contribute to ethical
place-making in care settings by encouraging, or even
requiring, educational institutions on their soil to train care
workers to meet local needs. It is not my intention to argue
here that they should be denied education and training that
would enable them to work in more amply-resourced
environments, but rather, that the emphasis ought to be on
the needs of the local population for the sake of reducing
health inequities over time.
Governments in source and destination countries alike
should play a key role in ethical place-making by regulating
the flow of care workers, especially from low and
middle-income countries to wealthy countries, through biand multi-lateral agreements. These involve arranging for
supplies of health professionals from particular countries
and not those with a low population/care worker ratio
population ratios and/or high disease burdens for specified
lengths of time to address particular skill shortages in specific
settings.

Both governments and employers in high-income countries

should honor voluntary codes of ethical recruitment. Nearly
twenty such codes have been developed, by governments,
associations of governments, non-governmental organizations
(the International Council of Nurses, for example), and health
professional associations (such as the World Health Organization and American Public Health Association). Such strategies,
which can be read partly as instruments of solidarity, can help
to make source countries themselves places less vulnerable to
unscrupulous recruiting practices and, most importantly,
enable low and middle-income source countries to create and
sustain care settings that allow for more equitable prospects for
their people. Later I note the necessity of accounting for our
relational autonomy and acting in solidarity to build on these
kinds of discrete efforts to design mechanisms and institutions
aimed at global governance for health equity.
Ordinary citizens can contribute to ethical place-making
in source countries' care contexts. While politicallegal
institutional reforms are essential, we must also consider the
potential of personal interactions and practices, or the
social labour and modes of practice that supply the ethical
and political soil within which the norms, institutions and
procedures of global justice are rooted (Kurasawa, 2007: 6).
When it comes to the health inequities perpetuated and
worsened by care worker migration, individuals and families
(especially in middle and upper-income brackets) in wealthy
countries might, out of appreciation for relational autonomy
and motivated by solidarity, practice what Kurasaw terms
preventive foresight. In this context, this calls for family
members to plan ahead for long-term and other health care
needs and to think critically about their anticipated use of
resources. They might ask themselves, for example: Is there a
difference between our expectations for care and our needs?
To what extent might these expectations or actual needs
have harmful implications for care workers, as well as others
in need of care abroad, especially in less well-off places like
source countries with health worker shortages? Could we
plan and provide for care needs in such a way that we might
avoid or lessen participation in the perpetuation of injustice?
Preventive foresight can at least help reduce the potential for
creating conditions of deprivation abroad so that people
dwelling in low- and middle-income countries with high
disease and disability burdens and health worker shortages
have better prospects for freedom and equity, while, if policy
makers act responsibly, residents of affluent nations receive
needed care.

Destination countries and their care settings

Care not only is essential for individuals; but it also
generates fundamental public goods people with social skills
who when they are healthy can be relied on to be good
family members, community participants, and citizens
(Folbre, 1999). The work of caregivers is at the very core of
social organization and reproduction, and indeed the foundation of citizenship (Tronto, 2006). Ethical place-making
calls for governments in destination countries to reform
immigration policies that deny care workers most often
those classified as unskilled who help to sustain citizens,
the benefits of citizenship.

Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

It calls, further, for transforming workplaces also places

of (mostly poor quality) care in high-income countries so
that they protect the health of workers, nurture, instead of
constrain, autonomy, cultivate a meaningful sense of inclusion, and nurture parity of compensation, voice and participation. Hospital-based nurses often cite poor working
conditions (Berliner & Ginzberg, 2002; Royal College of
Nursing, 2007), but nurses and other care workers employed
in long-term care confront some of the worst (Miller, Booth,
& Mor, 2008). Nurses and care workers in lower level
positions report high rates of job stress and low satisfaction
with their jobs, if not necessarily their line of work (Castle,
Engberg, Anderson, & Men, 2007; McGilton, McGillis Hall,
Wodchis, & Petroz, 2007). Regarded as unskilled, they
enjoy little if any respect, earn extremely low wages and tend
to lack benefits, including health insurance and sick leave
(Paraprofessional Health Institute, 2011). Yet they have
higher than average rates of diabetes, asthma, and other
chronic conditions, and have one of the highest rates of
job-related injury among all occupations (U.S. Bureau of
Labor Statistics, 2009). Migrants are especially vulnerable in
such settings (Aronson & Neysmith, 2001; Iecovich, 2011).
For migrant care workers specifically, ethical place-making at
minimum requires policies that ensure equitable pay,
benefits, and worker protection for migrant care workers
when their training and responsibilities are equivalent to
natives'. It also requires acting in solidarity to make
workplaces ethical for family caregivers through crafting
just leave policies that reflect and respect relational autonomy and do not harm health, though this is also beyond the
scope of my argument here.
Here, too, there is an important place for practices on
the part of individuals, particularly those dependent upon
migrant care workers. One has particularly rich potential:
recognition. Building upon the notion of respect for persons,
recognition so far has been theorized as a moral capacity
that can be expressed in several interrelated senses:
recognition of another as an autonomous individual deserving of equality; recognition of an individual's unique, highly
particular identity; recognition of persons as being members
of and in association with particular communities or groups;
and recognition of others' needs for relationships and
belonging, both interpersonal and associative (Benhabib,
1992; Fraser & Honneth, 2003; Gould, 2007, 2008). Each of
these dimensions of recognition can contribute to ethical
place-making for migrants by helping to create work
environments that don't erode their health and freedom,
that enable them to develop and expand their capacities as
individuals and professionals.
Recognition of nurses, nurse aides, and home care
workers as persons, their structural position, and the
inevitable asymmetries mediating all interactions serve as
starting points. Also due for ethical place-making is recognition of the particularities of: the conditions under which they
have migrated, under which they have taken a particular job,
and of their goals for migration; their particular expertise and
experience. Explicit acknowledgment of their interdependence is called for, for instance appreciation that many live in
transnational families and are absent citizens of another
society and, that this has implications for moral and political
agency. Crucially, people in destination countries owe care

workers' recognition of their contribution to the family and

to the society in which she's employed, that is, helping to
nurture and sustain identities and the places they inhabit.
Family caregivers in destination countries as well as paid
careworkers who are native have overlap in their experience
of injustice that should form the basis for solidaristic action
aimed, for instance, at workplace policies and conditions and
the gendered division of care labor.
A fourth dimension of recognition should be added:
explicit recognition of the places from which migrants come
(their countries and their health systems). This can manifest
itself in advocacy for more just policies domestic and
transnational concerning human health resources. The
practice of recognition can lead to not only social change in
the sense of care-setting reform and justice for migrant care
workers, but also, perhaps, change in the self-understandings
of citizens dwelling in high-income countries. Recognition
should lead to solidarity and, in turn, greater justice in global
health and the treatment of migrant workers.
Finally, the codes and agreements mentioned above
represent the beginnings of what should ultimately evolve
into shared governance over human health resources. Policy
discussions about human health resources in well-off parts of
the world are typically framed in nationalist terms (OECD,
2005) ignoring global connections and the rapidly growing
structure of health workforce interdependence even as it
flourishes in plain sight, along with its inequities. Ethical
place-making demands integrated health, and labor, economic, and immigration policy-making. Solidarity is an a
especially rich principle for motivating and guiding such
efforts (Eckenwiler, Chung, & Straehle, 2012).
Conclusion
The migration of women from low- and middle-income
countries with high burdens of disease and disability to
wealthier and comparatively well-resourced parts of the
world for work in health and long-term care settings
threatens to deplete or even eviscerate their home countries'
health care systems and exacerbate global health inequities.
It also is likely, all things considered, to constrain their
autonomy and undermine their own prospects for equity. I
have argued that governments and their citizens, along with
other agents whose policies and practices transcend borders,
should embrace the norm of ethical place-making to address
health inequities manifest in the places in which people who
need it receive care, and in which migrant care workers
provide it. I have outlined five key elements that, where in
place or emerging, enable people, conceived ecologically, to
realize justice. Source countries, destination countries, and
their care settings require and are due such social change.
Acknowledgments
Sincere thanks to the editors and anonymous reviewers
for their helpful comments.
Endnotes
1
The ideas offered by Tiina Vaittinen (2014) in this issue suggest a
related line of inquiry that warrants further exploration.

Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
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L. Eckenwiler / Women's Studies International Forum xxx (2014) xxxxxx

2
There is a tremendously rich and growing literature on solidarity,
particularly global solidarity that I do not pretend to capture in this brief
discussion. See Eckenwiler, Chung and Straehle, 2012 for selected sources.
3
Nussbaum, for her part, calls on us to embrace a more Aristotelian, less
Kantian image of the person, bringing the rational and the animal into a
more intimate relation with one another (2006: 54). This has the benet
not only of acknowledging that there are many types of dignity in the
world It also helps to account for our relationality and embeddedness in
habitats in a way that the undue emphasis on reason as the principal, if not
sole, source of dignity cannot. It also captures that we consume and excrete,
relying on the resources around us.

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Please cite this article as: Eckenwiler, L., Care worker migration, global health equity, and ethical place-making, Women's Studies
International Forum (2014), http://dx.doi.org/10.1016/j.wsif.2014.04.003