"Home’s Best: Dutch Discourse on Care and Independent Living" David Bos, Fenneke Wekker & Jan Willem Duyvendak In the Netherlands, as in many other Western countries, the welfare state is being fundamentally reorganized, notably in the...
more"Home’s Best: Dutch Discourse on Care and Independent Living"
David Bos, Fenneke Wekker & Jan Willem Duyvendak
In the Netherlands, as in many other Western countries, the welfare state is being fundamentally reorganized, notably in the field of long-term care (LTC). With its 2007 Social Support Act (Wmo), the Dutch government has begun to shift the responsibility for the frail elderly and people with psychiatric illness, physical or intellectual disabilities to the municipalities – which, in their turn, transfer it to ‘the community’. The net result is a drastic reduction of formal – i.e. professional, institutional, state-funded – care, and the ‘responsibilization’ of citizens for their relatives, friends, acquaintances, and neighbors.
In policy discourse, this devolution of the welfare state is often presented as a return to a ‘normal’, ‘natural’ state of affairs, bringing back care in the social setting where it allegedly belongs: ‘home’. Informal care, it is often argued, is not only cheaper, but more satisfying since it can be provided within the privacy and warmth of people’s ‘familiar surroundings’. As other authors have observed, the irony of this discourse is that it echoes social criticism of ‘institutions’, voiced in the 1960s and 70s by left-wing scholars and social movements, while it simultaneously appeals to conservative communitarian ideals.
In this article, we will further clarify this transmutation by analyzing fragments of 20th century Dutch discourse on a basic question: where, in what sort of setting, is care best provided? It will come as no surprise that in the past, too, the answer to this question often was: ‘home’.
For centuries, the Dutch have been known for their ‘domesticity’, and ‘domestication’ remains a dominant strategy in Dutch ways of dealing with the social and moral risks of teenage sex, sex work, alcohol and illegal drugs, birth and death. The relatively low percentage of Dutch women with full-time paid job also seems to indicate a partiality for ‘home’. Yet, in comparison with other Western countries, the Netherlands continue to have a relatively large number of frail elderly and people with disabilities or illness in residential care facilities. Despite the massive support for ‘critical psychiatry’ in the 1970s, ‘deinstitutionalization’ has been effected on a much smaller scale than in Sweden or Britain, leave alone Italy and the US.
The predominance of these institutions is partly a result of the Netherlands history of segmented pluralism alias ‘pillarization’. From the last quarter of the 19th century until well into the 20th, the various religious-ideological ‘pillars’ (notably Catholics and Orthodox Protestants) rivaled with each another and with central government in organizational power. Just like schools and hospitals, residential care facilities created facts on the ground in the battle over civil society, and offered meaningful jobs for young women and men. Until the 1970s, these institutions were not perceived as the opposite of ‘home’, but rather as an extension of it. If the care they offered was based on the proper principles – so it was believed – one could be ‘institutionalized’ there, and yet remain ‘within one’s own circle’. Consequently, debates on the provision care tended to be much more about the power balance between government agencies and, on the other hand, private charities or private enterprise than about intramural vs. extramural care. This only changed in the 1970s, when the pillars collapsed, and gave way to new professional regimes.
In at least one field, extramural, ‘outpatient’ care continued to dominate. Until the present day, in comparison with other Western countries, a very high percentage of Dutch women give birth at home instead of being hospitalized. It is our contention that this peculiar tradition has been facilitated not only by the power of Dutch midwives – as other authors have argued – and the Netherlands’ dense network of district nursing, but by a discourse that rhetorically equates the difference between ‘home’ and ‘hospital’ (or a home) with ‘familiar’ versus ‘strange’, ‘self-determination’ and ‘self-confidence’ versus ‘powerlessness’, ‘activity’ versus ‘passivity’, ‘person’ versus ‘patient’, ‘normal’ versus ‘medical’, ‘social’ versus ‘clinical’, ‘natural’ versus ‘technical’, ‘lay’ versus ‘professional’. This discourse also pertains to other parts of health care and the social services. In this article, we will present examples from post-war Dutch psychiatry and, more importantly, care for the elderly.
The latter sector is particularly interesting because during the third quarter of the 20th century, the percentage of institutionalized elderly Dutch citizens rose to an unprecedented, and internationally unparalleled level – from 3.7% in 1950 to 9.1% in 1975 – only to start a steady decrease since then. Interestingly, both in the years of ‘institutionalization’ and in those of ‘deinstitutionalization’ – which continue until the present day – a key term and central value in policy discourse on for the elderly has been ‘independent living’. We will explain this by bringing to light a subtle, but important semantic shift.
In the 1950s and 60s, when geriatric care began to emancipate from poor relief, ‘independence’ primarily meant ‘self-determination’: the freedom of elderly people to live their own life. In the majority of pre-war homes, which were basically poorhouses, this freedom had been all but a matter of course. Just like the inmates of other total institutions, the elderly were subjected to a strict regime, and enjoyed very little privacy. By contrast, the convalescent homes that mushroomed after World War II, let elderly people – or so they claimed – ‘go their own way’. In the 1970s, however, ‘independent living’ gained a new meaning, which was fundamentally incompatible with institutionalization. Instead of ‘self-determination’ it came to mean ‘self-reliance’ – abstaining from institutional, professional, or at least publicly funded care.
‘Self-reliance’ is at odds with ‘good care’, but this tension – so we will argue – has been covered up by a discourse that focuses on ‘home’. It is our contention that ‘home’ is politically irresistible because it epitomizes both the liberal ideal of being free from interference, and the communitarian ideal of taking care of one another. Hard though these two ideals are to reconcile – if only because of their implicitly gendered character – they found each other ‘at home.’
