Years ago, at a long lunch, my brilliant and irreverent friend Sophie suggested that all her girlfriends should move under one roof when we got very old, à la Golden Girls. It would be called “Shady Pines” and the staff would be very attractive young men. Ah! We raised a glass to that! But we wouldn’t need to think about this anytime soon, right?!

Earlier this month my 88-year-old mother broke her pelvis. Cécile fell in front of her seniors’ residence in Montreal just as I was leaving her. It had been a “good” day, but one where I could tell that her memory and cognition had eroded some more since my previous visit, only a month earlier. Cécile was diagnosed with Alzheimer’s two years ago. To say it’s a cruel disease seems like a cliché. But it is cruel to Cécile—eating away at her vibrant personality. For now, she still recognizes her children. But her older memories—those that had so far remained safe from the disease—are now dissolving. Her childhood is blending with her 55 years of married life, resulting, as she reminisces, in improbable and sometimes hilarious juxtapositions of events and people. But that day, she looked at me with her beautiful, piercing blue eyes and said to me for the first time, point-blank: “I’m losing my memory.”

Each goodbye is poignant, because my mother is not quite the same the next time I see her. These past few months, she has been clinging to me as I leave, a bit plaintive and teary—something she never used to do. And yet I turn away and fly back to New York, with a heavy heart every time.

Needless to say, I didn’t go back to New York that day. It’s been a blur of ambulance rides, emergency rooms, two hospitals, and now, for the foreseeable future, a geriatric rehabilitation center. Keeping a person pain-free, comfortable, fed, clean, bathed, changed into new clothes… is exhausting, mind-numbing work. It’s not any easier, and possibly even harder, when that person is my mother, who tells me accusingly that wearing a diaper is humiliating for her, or announces cheerfully that she’s going to grab her purse and keys and leave the rehab facility with me.

I’m fortunate that this happened in Canada, where Universal Health Coverage is (still) a reality, despite right-wing attempts to privatize it; where healthcare is a right, and where no billing department or insurance company will ever contact me; where healthcare, even after COVID and despite serious staffing shortages, continues to provide quality, patient-centered care. I had not dealt with the Canadian healthcare system since 1994. It was nothing short of miraculous to see the system operate, although overextended and still functioning in pandemic mode. Maman was given a scan, ultrasound, and X-rays, and was transferred and assessed by the top orthopedic team in Montréal in less than 18 hours. In each facility, the doctors, nurses, nurse assistants, orderlies and cleaners were wonder workers—their professionalism, kindness, stamina and patience were astonishing.

As I sat by my mother’s side over many days, I reflected on how lucky she was to be white. I thought of Joyce Echaquan, a 37-year-old Atikamekw (Indigenous) woman who died in the emergency room in a Quebec hospital in 2020 while filming her own demise on her smartphone, with white nurses ignoring her pleas and making racist remarks within earshot (and on tape). This shocked white Quebecers, but it wasn’t a surprise to their Black, brown and Indigenous neighbors.

Yet that is the very same health system that is sustained by immigrant women (and some men) of color: excellent and dedicated staff who took care of my mother, like Drs. Saoud, Kather and Diaz, nurses Ophélie, Chika, Annie and Soledad, and nurse assistants Celia, Judeline and Moustafa. I’m deeply grateful to them, but can't help but wonder at the economics and power dynamics behind this state of affairs.

The World Health Organization reports that 70% of health and care workers globally are women, who provide essential health services for about 5 billion people; yet only 25% of people in positions of leadership in healthcare are women. In Canada, immigrant women of color make up 30% of those at the lowest staff levels (nurse assistants and orderlies), while women as a whole account for 86% of the staff in those occupations. In Montréal, 48% of nurse assistants and orderlies are immigrants, while in Toronto it’s 78%, with Black Caribbean and Filipino immigrant women representing the bulk of this group. These workers are also overqualified: 45% of the most recent immigrants working as nurse assistants and orderlies had at least a bachelor’s degree (often a nursing degree), as opposed to 5% of non-immigrants in those jobs.

Canada, the United States, Australia and many countries in Europe and in the Gulf attract these health workers from lower-and middle-income countries (LMICs). It’s a perfectly rational personal decision to move in search of a better life. But this hard-working, overqualified, low-wage female labor force becomes a feature of the system in high-income countries (HICs). Health and care systems in the global North balance their budgets on the cheaper labor of these very same women, while LMICs face an acute shortage of healthcare workers. Certain African countries lose up to 70% of their health workforce to HICs. Approximately 65,000 African-born physicians and 70,000 African-born professional nurses are currently working overseas in HICs, while home care aides in HICs are overwhelmingly fromLMICs. Ensuring these workers are paid and treated properly around the world could shift that dynamic.

It’s obvious that in both the global North and South, care systems also rely on the unpaid labor of women: wives, daughters, sisters or grandmothers. Cécile has three daughters, a granddaughter, nieces, and cousins who have been supplementing professional care for years. This is a gendered phenomenon common around the world. In 2015 in the US, about a quarter of women aged 45 to 64 and one in seven of those 35 to 44 were caring for an older relative.

Caregivers spent about 20 hours a week providing that care, usually while holding a full-time job. Women report that they pare back their hours or switch to a less demanding job in order to provide eldercare. This is unsustainable and needs to be addressed by policies grounded in an “ethics of care,” with publicly funded, universal eldercare. Ai-Jen Poo, the president of the US-based National Domestic Workers Alliance, believes that, “without public intervention, there will be a humanitarian crisis, both for the aging and the workers that care for them.” The crisis is already here. Elder care also needs to be a feminist clarion call. As noted by Liz O’Donnell in The Crisis Facing America’s Working Daughters in the Atlantic:

“These same women are expected to live well into their mid-80s, and outlive (by about two years) the average man. How will they afford their own care later in life if they can’t save for it at midlife while they are caring for someone else?”

Adrienne Germain in 2010

On May 20, as I was leaving the rehab center at the end of the day, a letter from Adrienne Germain hit my inbox. Adrienne was one of the founders of the International Women’s Health Coalition (IWHC), where I worked for twelve years—in International Policy and later, as President. In the letter, Adrienne explained that she had peacefully ended her life the day before, at the age of 75, in her apartment in Oakland, California. I sat down at the bus stop, shocked and overwhelmed.

Adrienne’s letter is not sad, nor self-pitying:

“As you know, I’ve been wondrously happy in Oakland, indulging my longstanding love of the Bay Area; reflecting on the myriad satisfactions, as well as some disappointments, of my life; and recalling each of you, our escapades and accomplishments. But, as I increasingly lost the lifelong strengths I’d relied on, I deliberately began moving toward my end, knowing I’d done all that I could for justice and could do no more. In the last couple of years, as even the delights of retirement diminished, I decided to end my life while still joyful and autonomous, at peace with myself, rather than let aging compromise my joy and memories of a productive, rewarding and well-lived life.

Some or all of you may find this hard to accept or even understand, but it’s fully in character. Self-determination is central to who I am and how I’ve lived. I hope you’ll take comfort in knowing that I ended my life happy, proud I had the courage to do so despite the stigma generally attached to such action.”

Adrienne was phenomenal: a brilliant thinker, writer and strategist, a stalwart feminist, and a fierce and passionate advocate for women’s control of their bodies, sexuality and reproduction. She inspired many to take on this struggle, and IWHC supported many feminist activists around the world to push for change in their own contexts. I was privileged to consider her as a mentor and to count among her friends. Now I will never be able to enjoy her sharp mind and vast knowledge again: it's a huge loss. She and I had a long lunch last July in San Francisco, and it was a true pleasure and comfort to talk about our common interests and travails. Her death comes too soon—for me, for her friends and her many colleagues in the feminist movement. But not for her, evidently.

All who knew, loved and admired Adrienne had the same sad, grudging but affectionate thought when they heard the news: “This is so Adrienne.” Fearless, rational, in control. Also: alone. She had very dear older friends nearby and far afield, but no children or younger relatives, and she was not wealthy. She was also very concerned about “living too long.” I accept that, and I completely respect her decision, but I am grieving and shaken.

On the train to DC in April 2004 for the March for Women’s Lives: Corinne Whitaker, Astrid Bant, Adrienne Germain and me.

I can’t help wondering if, in many countries, being an older woman of average means who lives alone doesn’t become a terrifying prospect at a certain point. The US is notable for one of the harshest, least generous approaches to care—it doesn’t even have federally-mandated paid maternity leave, and people need to drain their bank accounts and dispose of their assets to become eligible for government-funded eldercare. It wouldn’t be hard to do better in terms of policy. But in fact, COVID revealed the deep inadequacies of eldercare everywhere, with residents and staff in long-term care settings dying at record rates worldwide. Women who “live too long” and those who care for them are obviously not valued as they should be. Is Adrienne’s choice the one more of us will contemplate as we getolder? Is this a step many older women will take?

It’s high time to demand a proper, public system of care, from childcare to eldercare, and for those with a disability. And also plan for Shady Pines?

In feminist solidarity and care,