Rituals of Care: Karmic Politics in an Aging Thailand

RITUALS OF CARE

Karmic Politics in an Aging Thailand

Felicity Aulino

CORNELL UNIVERSITY PRESS ITHACA AND LONDON

To my parents

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

Acknowledgments

So many wonderful people made this project possible and have supported me through the years of research and writing. I am told the acknowledgments cannot be longer than the book itself, so here I will name but a few of the generous souls who have made this experience so very rich. To the friends, the funders, and the winds of fate that helped bring this work to fruition—I thank you so.

Deepest thanks go to my friend and mentor Linchong Pothiban, of Chiang Mai University’s Faculty of Nursing. She set this project on its course and nurtured me and my family every step of the way. Immense gratitude also goes to Sawang Kaewkantha, who was a constant guide and ally, and who opened up the world of elder care in Thailand to me.

I use pseudonyms for most of the people who appear in this book, though I am deeply grateful for their every assistance, great and small. Words in fact cannot express the gratitude I feel for everyone who allowed me to occupy the strange role of anthropologist and to live and work in their midst. Particular thanks goes to my family in Nong Hoi.

The research and writing represented here was made possible by generous grant support. My thanks go to the Social Science Research Council, the Wenner-Gren Foundation, the Harvard Committee on General Scholarships, the Mellon Foundation, and the Templeton Foundation.

Thanks unending to Mary-Jo DelVecchio Good, my mentor since college, without whom none of this would have been possible; Byron Good, an intellectual interlocutor beyond compare; Arthur Kleinman, an incredibly generous teacher, reader, and guide; Michael Herzfeld, an ally with great taste and superb attention to detail; and Michael Puett, whose enthusiasm and insight have proven inspirational at every turn. Michael M. J. Fischer has shown me what masterful scholarship looks like, and I thank him for his feedback on this project. Charles Hallisey remains a steadfast guide. Thank you to Paul Farmer, Anne Becker, Salmaan Keshavjee, and Arthur Kleinman, and the entire crew of Societies of the World 25, who taught me an enormous amount about global health practice and pedagogy, greatly influencing my thinking. Thank you to all my teachers, including the late Stanley J. Tambiah, who was a good friend and through whom I came to appreciate the power of history and the disorienting strength of radical egalitarianism. And above all, thank you to Aba Cecile McHardy, the Friendly Dragon, a guide in life and scholarship to whom I remain devoted across lifetimes; her influence can be marked on every page.

In Thailand, countless friends have guided my way and my understanding. A particularly warm thanks goes to Tana Nilchaikovit, from whom I have learned so much on so many levels. Deep appreciation, too, to Komatra Chuengsatiansup, a great mentor at home and abroad. Thank you to those working tirelessly with and for older people: Ajarn Aphassree Cheikuna, Phannaphat Mam Phophaenna, Janevit Wisojsongkram, Saranyu Win Kaewkantha, P’A, P’Jeu, Sirinat Sonia Kasikam, Nong X, Sirinapa O-way, Nong Eunjai, Usa Khierwrord, and Somporn Nok Kiokaew. Additional thanks to Nong Way for her assistance, along with Sukyunya Pornsopakul, Duen Heang, and the incomparable Sangwan Poo Palee. Thanks go to the palliative care experts who taught me so much, including Veeramonl Chantaradee, Dr. Issarang Nuchprayoon, Wasinee Wisesrith, and Dr. Mano Laohavanich. Special thanks to the palliative care team at the Songklanagarind Hospital, Prince Songkla University, in Hat Yai, including Temsak Phungrassami, Sakon Singha, P’Fong, and P’Yae. Thanks also to everyone at the Phuthikā Network, including Phra Paisal Wisalo and Sui Wanna Jarusombun. Thanks to Win Pop Mektri and to everyone at the Volunteer Spirit Network for generous access to the library. And my gratitude to the incredible scholars, policymakers, and practitioners for their time, work, and generosity, including John Knodel, Wipada Kunaviktikul, Wichit Sisopan, Siriphan Sasat, Bprasaan Tangchai, Tanet Wongyanawa, Naret Songkrawsook, Khwanchai Visithanon, Virapun Wirojratana, Samrit Srithamrongsawat, Suriya Wongkongkrathep, Weerasak Muangpaisan, P’Kaek, and Usamard Siampukdee.

A lifetime of gratitude to all my amazing colleagues in the Pioneer Valley for their support and inspiration in growing this work, including (but not at all limited to) Sonya Atalay, Elif Babül, Whitney Battle-Baptiste, Sue Darlington, Chris Dole, Deborah Gewertz, Alan Goodman, Suzanne Gottschang, Jennifer Hamilton, Krista Harper, Maria Heim (a game changer), Julie Hemment, Betsy Krause, Tom Leatherman, Lynne Morgan, Joshua Roth, Andy Rotman, Sahar Sadjadi, Boone Shear, Pam Stone, and Jackie Urla. Thank you to the Five Colleges and everyone in Culture, Health, and Science. And thank you Jen Sandler for critical relationality, and for guiding me to others naming and practicing transformative change.

My gratitude to Tanya Luhrmann for including me in the Mind and Spirit Project, which gave final direction to this work, and to the crew: Josh Brahinsky, John Dulin, Emily Ng, Rachel Smith, plus Kara Weisman, Vivian Dzokoto, and Nikki Ross-Zehnder. Hard to single out, but, Josh, thank you for the structuring commutes; and Emily, thank you for reading and naming and g-chatting through it all.

Thank you and continued loyalty to the original Thai writing group: Eli Elinoff, Malavika Reddy, Claudio Sopranzetti, and Benjamin Tausig. Claudio, you made it all possible—as friend and brother, we delight in and count on knowing you in the world. Lisa Stevenson, thank you for everything, for getting and supporting it all. And heartfelt thanks to other colleagues, friends, teachers, and family (and all combinations thereof) for their immense instrumental support, great insight, and good humor: Adisorn Juntrasook, Addy and Nick Grossman, Adia Benton, Akiko Mori, Andrew Johnson, Anna Corwin, Aroon Puritat, Barbara Barry, Bob Bickner, all the wonderful Thai teachers and my fellow students in Madison, Bonnie Brereton, Brooke Schedneck, Carey Clouse, Charlie Carstens, Chuck and Molly, Diarra Lamar, Donald Swearer, Eduardo Kohn, Elana Buch, Emiko Ohnuki, Erick White, everyone at the land foundation, Gernot Huber, Jamie Burford, Jason Danely, Jeffrey Samuels, Jeremy Smith, Jo Cook, Joe Harris, Julia Cassaniti, Kristina Lyons, Kurt Wise, Larry Ashmun, Kate Mason, Margaret Wiener, Marilyn Goodrich, Marisa Guptarak, Matt Yoxall, Mau Daw, Milena Marchesi, Mook MS, Mui Cheewintha Boon-Long, Nick Thomson, Non Arkaraprasertkul, Oriana Walker, Peggy Aulino, Pote Videt, Rachel Broudy, Raeann LeBlanc, Rebecca Hall, Roseanne Carrara, Saipin Suputtamongkol, Scott Stonington (a gem in the world, partner in this work), Shika Card, Smita Lahiri, Toby Lee, Tom Blair, Tom Borchart, Vicky Koski-Karell, Wirun Limsawart, Yoko Hayami, and Yuyang Mei. I could write pages on each and every one of you; such warmth to you all! Anitra Grisales, thank you for taking me on and providing insight and a formidably edited path to follow. And thanks, too, to Jim Lance, peer reviewers, and everyone at Cornell University Press for supporting this book—thrilling beyond belief.

I learned a lot about caregiving—its mixtures of sacrifice and devotion and love and simply showing up—perhaps most vividly in my own home. My mom spent eleven hours a day with us, caring for baby Ren her first year as I wrote the first iteration of this book, and my dad endured so much time alone to let her go. In the years since, they have done all the more, from the daily for baby Eamonn to reading these words and cheering me on. And sweetest Kevin Moore, a second dedication to you and the kiddos too for making this with me, wondrously turning all trials and travails into adventures. I love you.

Note on Names and Thai Transliteration

Names have been changed to protect the privacy of the people in this book, except for public figures speaking on the record.

Throughout, I use primarily the Romanization scheme of the American Library Association—Library of Congress (ALA-LC) for transliteration of the Thai language. Exceptions include abbreviations and words commonly transliterated otherwise (such as jai for ใจ, as opposed to the formal ALA-LC čhai).

Introduction

AN INVITATION TO CARE

Boonyuang takes hold of her mother by the armpits and yanks her up to the top of her bed with several rapid, forceful movements. A slight grimace passes over the older woman’s face and is quickly gone. It is the first changing of the day, and, softly muttering dirty, dirty (sokaprok, sokaprok, สกปรก ๆ), Boonyuang gets on with her routine. She tosses aside the top sheet and unfastens her mother’s nighttime diaper. The pungent smell of loose stool fills their small room, as Boonyuang pushes her mother’s semi-paralyzed frame over onto her left hip to gain access to her backside. With gruff and practiced hands, she makes quick work of cleaning and powdering. As she affixes a new diaper with a twisting configuration of rubber bands, she explains that the sticky tape provided on the Pampers’ ends is not strong enough to hold the sides together. Months of trial and error have led to the system now in place. Boonyuang next reaches for a scrub brush and lifts her mother’s one usable hand up as she whisks back and forth across dainty nails soiled by self-exploration. Each action is rough and unapologetic, and at the same time skilled and effective. Boonyuang deftly moves the elder’s legs into a pair of brightly patterned pants to finish the job, and deposits the bedding into a basin for her next task of the day.

Boonyuang, at age seventy, is the primary caregiver for her bedridden ninety-two-year-old mother, Yāi Maw.¹ The two live together in Chiang Mai’s old town, the inner moated area of the largest city in Northern Thailand. Situated behind a modest faux-brick house off a narrow alleyway that snakes behind the white exterior wall of an ornate temple close to the northern wall of the city, their wooden home is reminiscent of a traditional Lanna-style dwelling—though instead of an open-air ground floor, the lower portion of the structure has been enclosed. Boonyuang rents out the upper level, leaving only the cramped underside, with wooden plank walls and ceilings no more than five feet high, for her and her mother. Boonyuang is not much more than four feet tall, and her mother cannot sit up, so they somehow manage (without having to duck, unlike some visitors) as they go about their daily affairs.

Yāi Maw had been a vegetable seller for decades. She used to carry regularly two heavy baskets balanced on her shoulder with a long pole, work that led to her increasing discomfort over the years. She is now largely deaf, nearly blind, and entirely incontinent, with excruciating pain in her back and no desire (or ability) to leave the house. She spends her days and nights on a donated hospital bed, its metal arms raised to keep her penned in, with a partial view to the outside world through the slatted panes of a small window and the screen of the door, when open. On her bed just within reach lie a blue plastic flashlight and a back scratcher. The metal table beside her is lined with pill bottles, packages of crackers, and a cup with a bendy straw, along with a transistor radio, which is either turned up to full volume or droning quietly, unnoticed. Behind her, above the head of Boonyuang’s bed, which takes up the remainder of their one room, an array of pictures covers the wall: several revered monks; the nation’s king; a bright eight-by-twelve portrait of an older man, Boonyuang’s late husband, set against a background of bright blue sky and white puffy clouds; a photograph of a beautiful young woman, Boonyuang’s daughter, clad in a university uniform, complete with white collared shirt and half smile. These are deceased family members, departed too soon.²

Boonyuang will shortly perch on a stool outside, bent over three buckets. She gets going with the wash in a small orange bucket, the type sold around town filled with toiletries and other necessities to be donated to Buddhist monks clad in robes of the same hue. Once scrubbed, the sheets are transferred to another soap-filled bucket, this one pink. Boonyuang puts her back into the motions as she stoops, lifts, and repeats, concluding with a final rinse with plain water in the largest of the plastic vessels. After the balance of water is wrung out, the laundry is hung to dry, looking like oversized prayer flags on lines crisscrossing the side yard. On my first visit, Boonyuang remarks as she washes that she does this three or four times per day. Occasionally a volunteer from a local nongovernmental organization (NGO) will stop by with some offering of money, brochures, or community news; some days a visitor turns up with sweets or a fresh supply of diapers. And so my introduction to care in this northern city of Thailand begins.

The scene can be astonishing at first pass. An aged daughter and her elderly mother in an impossibly small room, stuffed with first-aid supplies, with an endless stream of chores to keep their humble household running. But it has been this way for years. However unsettling the state of affairs may seem to outsiders witnessing it for the first time, the situation has become ordinary. And it is this very ordinariness that I seek to explore in this book. My focus is care in the everyday, and the ordinary is the route by which I want to bring attention to the habituated ways people provide for one another—not only at bedsides, but also in boardrooms, corner stores, or any number of mundane daily interactions. This focus illustrates that care is not universally parsed as a matter of concern and assistance, but rather is a function of the ways people’s attention is trained by the social world to perceive and prioritize what needs to be done, and for whom, and in what ways.

The ethnographic scenes depicted in this book will appear both familiar and strange to many readers. Thailand, this relatively small nation of sixty-six million people in mainland Southeast Asia, faces struggles similar to many other places in the world, including a rapidly aging population, the exploitation of the working and middle classes, and economic and authoritarian roadblocks to political participation. People care for the sick and provide for their communities amid such conditions, and much of what they do can be described, using familiar analytic concepts, as reflecting and resisting a variety of social pressures. But Thailand is also predominantly Buddhist, one of many indications of the powerful influence of centuries-old practice and philosophical lineages, distinct from European traditions, evident in arenas large and small, personal and political. Getting a handle on the sensibilities instilled by this social world is what I seek here. Close attention to mundane affairs—from home-care routines to friendly social interactions, from volunteer home visits to professional conference presentations—invites an appreciation of the subtle logics of engagement from which lived experience here stems.

Take a classic volunteer visit as a simple example. Yāi Maw’s neighborhood volunteer arrived one day around New Year with a caravan from a nearby older people’s organization. The team disembarked from the NGO’s tall, white, ten-passenger vehicle and wound their way back to the entrance of Boonyuang’s house, all in matching collared polo shirts and neatly pressed slacks. They held a brightly colored silk scarf folded tidily and encased in clear plastic. Greetings were exchanged as the group gracefully arranged themselves around the bed, squeezing in without disturbing any of the pair’s belongings, despite the tight space. The mood was markedly jovial, and everyone showered Yāi Maw with compliments on her strength and the skill of Boonyuang’s caretaking. They then presented the scarf as a gift, helping to arrange the old woman’s hands to accept the package. Everyone found some way to place a hand on the receiver as the offering was bestowed, whether directly or indirectly by touching the elbow of someone else closer in, forming a chain of merit made and captured by dozens of camera flashes. And as quickly as they had come, they were merrily off to their next destination.

In the chapters of this book, I hope to provide a sense of how and why situations like this are calibrated care in context. The perfunctoriness of the visit above in some ways mimics typical trips to Thai Buddhist temples, as I explore in chapter 1 in terms of the karma of care. The preparation of the items offered is essential, and neatness of presentation is well tended. The actions count and must be executed according to guiding parameters. When followed, there is social and spiritual care enacted in these forms, from the alleviation of karmic burdens to a resultant sense of comfort. That no one directly probed into the emotional well-being of Yāi Maw and Boonyuang is also fairly typical, as I discuss in chapter 2 in terms of the conditioning of care, representing a logic of psychosocial support geared to draw people’s focus away from their troubles and distress. The formality of the visit, even the height of people’s hands raised in greeting, indicates to all the relative status of members of the group. As people maneuver their bodies following the dictates of polite hierarchy, the nearly scripted sets of movements provide a felt stability to the gathering, even if temporarily. Such deployments of perception and power are discussed in chapter 3 in terms of care of the social body, and in chapter 5 in regard to the violence of care.

One might be tempted to focus on the abundance of resources expended in the affair sketched above; the event might then seem hollow, not only for the token offering but for the fleeting time spent volunteering in such an encounter. In turn, the scene could be enlisted to challenge a host of community aid projects that spend a great deal of time in a similar fashion. But while at some level such critique is warranted, as explored in the civic landscape of care presented in chapter 4, this scene can also reveal aspects of how people do meaningfully provide for one another, even if and when also failing to alleviate pressing burdens or enabling oppressive power relations. Attention to appearance, the correct application of ritual-type technologies, and hierarchical deference serve to decenter dominant Euro-American notions of functional utility, disrupt presumptions regarding the importance of sincerity and other psychological components of good care, and reflect important forms of care, however antithetical to egalitarian sensibilities such forms may be.

Indeed, in this book I aim to show how a focus on care can challenge and refine core anthropological concepts. Throughout, I trace how people’s attention is trained in Northern Thailand to enable the embodying of appropriate forms, and how little emphasis is placed on cultivating an authentic desire to provide for others. This changes the moral calculus of care as it is commonly conceived and helps draw out the particularities of underlying conceptions of the self. In turn, the stakes and the potential of care come into new focus.

I also find a focus on care offers a fresh angle on recent turmoil in Thailand from the vantage point—unusual for political analyses—of embodied practice. Ultimately, given the present struggle over existing norms in Thailand, I argue that the modes of being that are described here, through attention to everyday occurrences in Thai settings, can help open avenues for prompting radical change in settings worldwide, at both individual and structural levels. This is inspired not via abstract and universalizing calls to care, but through appreciation and transformation of mundane, habituated practices of providing for others.

Originations: From Dying to Aging to Living in the Everyday

I first met Boonyuang and Yāi Maw, along with a host of others discussed in this book, by way of a volunteer-based home-care project for elders in the Chiang Mai municipal area. In 2008, I partnered with this group—what I will call the Older People’s Organization, or OPO—as a home base from which to study end-of-life care and the budding hospice movement in Thailand. A strategic alliance among prominent medical doctors, health-care personnel, and Engaged Buddhist activists had placed end-of-life at the center of overarching social change efforts in the country. Hospice and palliative care services offer an alternative to biomedicine’s typical focus on cure—offering instead attention to physical, mental, and spiritual well-being. In a country in which an estimated 90–95 percent of the population is Buddhist, religious teachings can provide powerful rhetoric within the biomedical establishment as well as compelling practices in the personal realm. These end-of-life advocates in turn were harnessing Buddhist frameworks to change not only the culture of hospital death and home and community care for the dying, but also forms of interpersonal engagement in nearly every sector. I thus sought to explore what constitutes end-of-life care in different contexts, as well as how care for the dying had become a vehicle for large-scale social action.

OPO offered me entree to the homes of families caring for bedridden elders who, one might suspect, were prime candidates for this end-of-life movement. But as I began to work with these elder people and their caregivers, I realized that they did not talk about death in the ways I had been primed to expect by the palliative care literature. In clinical settings around the world, an inability to accept imminent death can lead to heroic lifesaving techniques that are not only costly, but often also increase the suffering of the patient and their loved ones. Terms such as end of life (rayasutthāi khǭng chīwit, ระยะสุดท้ายของชีวิต, literally last stage of life) are therefore essential for hospice, as they signal when a person is in need of a different orientation to care. But the people I met through OPO rarely used or volunteered terms like end of life, or even the more colloquial close to death (klai tāi, ใกล้ตาย). They were not focused on cure, and resistance to end-of-life language seemed more than simply a fear of or inability to confront death peacefully, as core trainings of Thai palliative care promote. People were caring in a different register.

A core strength of the ethnographic method is the ability to recognize when one’s research focus is projecting significance onto one area when what matters more to people lies elsewhere. I was faced with people caring in a different and seemingly important register, and it gradually dawned on me that my original research questions regarding care for the dying had an undue biomedical bias. The term end of life, so essential to hospice and palliative care discourse, is a relatively new, medically inflected phrase. It indexes a clinically rendered terminal prognosis, which is required to determine whether a person is in the so-called last stages of life and thus qualifies for hospice. Once a person qualifies, a range of services can be enacted to help prompt a peaceful death for all involved. Not only did home caregivers not use words like end of life and peaceful death, the long-term care routines they performed every day spoke to a way of being that was unrecognized by this rhetoric. Long-term care routines necessitated bodily action over and above the prognostic recognition and contemplation emphasized by hospice advocates. These routines manifested a mix of practicality, belief, and tradition in the everyday. A research focus on dying seemed an imposition on ordinary experience, experience that was itself worth exploring.

I therefore altered my research so as not to have my questions narrowly defined by the medical gaze, starting instead with the experience of lay caregivers for dependent elders and the organizations that support such work. I then came to appreciate the palliative care movement as it was cast in relief by a set of national platforms on aging and eldercare. Like their hospice counterparts, Thai population aging initiatives traded in international best practices, were steeped in Buddhist rhetoric, and aspired to spark social change in relation to a host of attitudes and practices.³ But unlike the bulk of palliative care efforts, eldercare initiatives were able to escape the centripetal force of biomedicine—at least in some ways.⁴ In turn, those providing eldercare ultimately reoriented my understanding of care more generally.

With the focus on eldercare came another proximate backdrop for analysis: population aging. Epidemiological and demographic transitions, economic forces, and new medical technologies have coalesced to increase long-term care needs in many societies. In turn, a political discourse of crisis is emerging around the world, as governments fashion trade agreements that include provisions for the movement of care workers and domestic programs attempt to meet the shifting care demands of citizens. Aging preparedness is a guiding buzzword. And, amid grand visions of restoring elders’ rightful place as esteemed members of society, the burden of physical care everywhere continues to fall largely on families, women, and marginalized peoples.

Thailand provides a prime example of this overall trend of population aging. Two generations of family planning efforts (beginning in the 1960s) reduced the total fertility rate from six children per woman to fewer than two, while medical advances increased life expectancy by about a decade during the same period. Older people (defined as those over the age of sixty) now make up over 13 percent of the total population, a percentage expected to increase steadily in the coming decades.⁵ These older people are said to face the prospect of dependency without traditional safety nets, as young people work outside the home to support their families and no longer have a large sibling base with whom to share the responsibilities of providing both monetarily and physically for their elders. Issues of eldercare are prominent in Thai society, as demographers and global health organizations trumpet the country’s aging society status, and personal narratives and national policies alike draw on a host of models circulating globally to address population inversions.⁶

Anthropologists have grappled in recent years with transformations of social norms caused by growing elder populations. Whether in terms of emergent elderscapes (Danely 2015) and cultural scripts (Long 2005), thwarted expectations and dominating decline narratives (Gullette 2004), or growing pressures to reimagine possibilities for eldercare, people around the world seem to be struggling with what will happen to them and to their societies as they age.⁷ Indeed, the changes signaled by new idealized visions for old age and long-term care are not superficial. They entail corresponding changes in religious ideology and cultural logics, as well as economic circumstances and social welfare systems (Lamb 2009). And although anthropologists are keen to point out false claims of universality in transnational discourse, such as found in the successful aging movement, recognizing the values, cultural assumptions, and political motivations built into circulating models of aging and long-term care, as important as that work is, may not be enough.⁸ Changes predicted and heralded by international demographic discourse must not dominate anthropological analysis of population aging, leaving room instead to appreciate subtle (and not-so-subtle) ruptures, continuities, and new formations in people’s lives. In turn, insights from eldercare can be shown to have great relevance for a broad range of social analyses.

The set of circumstances surrounding aging and eldercare in Thailand warrants consideration not only by those interested in health and caregiving issues, but also by those engaged in social and political struggles the world over. OPO, as I will describe, is one of the many programs springing up around the country with the explicit purpose of bracing for anticipated age-related social change in Thailand.⁹ Like their counterparts in the hospice movement, these programs start from a seemingly narrow set of goals (related to the well-being of older people) and quickly move out to a series of aspirations for societal relations more generally. Both eldercare and hospice advocates in Thailand aspire to ideal visions for open communication and health equity that require massive adjustments to the status quo. Yet their orientation to and promotion of such radical ideals, somewhat counterintuitively, remain enmeshed with traditional logics of care. And while both movements largely shied away from the more prominent and politically charged social change efforts bubbling up, and in fact boiling over, at the