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“Like a Queen”

1The European Social Science Section of the International Association of Gerontology and Geriatrics held a conference on “Ageing in the Mediterranean World” in Malta in March 2009. The stated goal of this conference and the book that resulted from it [Troisi and Kondratowitz, 2013] was to extend research perspectives on European social gerontology “to the dynamics and crystallization of the aging process in the whole Mediterranean region” [Kondratowitz, 2015: 36, emphasis in original], thus providing European scholars with an “alternative option for comparative analyses” [Kondratowitz, 2013: 6]. The conference was promoted and primarily attended by sociologists, who were joined by epidemiologists, demographers, economists, and a single anthropologist. This proposal to extend comparisons regarding ageing populations to the southern shore of the Mediterranean again raises, albeit in a different form, what has long been a classic and hotly debated issue in the anthropological study of Mediterranean societies. [1]

2Beginning in the 1950s, socio-cultural anthropologists tended to give pride of place to notions of honor and shame as salient features of the Mediterranean regions as a whole [Peristiany, 1966] and to treat the two shores of the Mediterranean as a single culture area. This broadly shared view came under attack in the 1980s, when the tendency to circumscribe comparison only to countries (or portions of countries) falling within the perimeter of the Mediterranean region was denounced by anthropologists including Herzfeld and Pina-Cabral as one of the “sins of Mediterraneism” [Horden and Purcell, 2000: 486]. Along with emerging geopolitical reasons—in particular the expansion and strengthening of what was to become the European Union—this critique led anthropologists to question the cultural unity of the Mediterranean and to move Portugal, Spain, Italy, and Greece “from the Mediterranean to Europe” [Goddard, 1994].

3The extension of the comparative horizon to the entire Mediterranean region now advocated by von Kondratowitz clearly goes in the opposite direction, as a remedy for a “sin of Europeanism” of which social gerontologists probably feel guilty, since they have long discarded the possibility of commonalities between the societies on the two shores of the Mediterranean. The growing body of research on southern Mediterranean countries, however, points to “many similarities with the southern EU member-states, including the heavy reliance on family for care and the lack of services to support older people and their carers” [Triantafillou and Mestheneos, 2013: 135]. In fact, the anthropologically relevant question is not whether the Mediterranean region is homogeneous or unique, but whether southern Europe looks closer in significant respects to the countries on the other side of the sea than to northwestern Europe. Ascertaining the existence of these similarities might also help dismantle a dichotomy which dominates the studies on ageing, family and support to the elderly in the countries of the south-eastern shore of the Mediterranean, that are variously labeled as “developing countries” or “East” as opposed to the developed West or, indeed, to a European society conceived of as indisputably wealthy and uniformly pervaded by Western values.

4Opinions are divided, though, and many scholars maintain that there is a sharp moral and structural divide between the two rims of the Mediterranean. The differences are illustrated by an exchange at the Malta conference, when one of the authors of this article advanced the hypothesis that the values on which the first generations of anthropologists working in the Mediterranean had insisted—the centrality of the family, strong moral obligations towards kin, and even honor and shame—may still represent a set of commonalities between the countries on the two shores of the Mediterranean and a marker with regard to northern Europe. This hypothesis was promptly rebutted by Youssef Courbage, the distinguished Lebanese demographer, who argued that southern Europe displays attitudes towards the elderly that would be unthinkable on the southeastern shore of the Mediterranean, as effectively epitomized by an Italian movie in which a son forces his mother to enter a retirement home. [2] The movie referred to by Courbage is one of fourteen episodes in a 1977 film entitled Viva l’Italia in the English-language version. More specifically, he had in mind the episode directed by Ettore Scola and entitled Like a Queen, which tells the story of a man who confines his mother to an old folks’ home, where the woman feels tricked and abandoned. She attempts to escape, but the son hands her back to nurses, who look like jailers. When the mother is taken away, however, he has a moment of repentance and cries to the nurses to treat his mother like a queen. Although at first glance this may be taken as evidence of an ethical divide between the two shores of the Mediterranean, on closer inspection it becomes apparent that the film was a sequel to a highly successful 1963 movie entitled I mostri (“The monsters”) and that the original Italian title of the sequel was I nuovi mostri, “The new monsters.” The goal of this episode, and more broadly of the entire film, was to portray despicable behaviors and express strong moral condemnation.

5As anecdotal as this example may be, nursing homes do offer a useful starting point to explore cultural and structural similarities and differences between northern Europe, southern Europe and the southern Mediterranean. It is worth recalling that in a highly influential article by David Reher, he uses retirement homes as a critical context in which to test his argument that major cultural contrasts existed and continue to persist between the northern and southern halves of Western Europe. His argument is that historically the aid given to the elderly in southern Europe came almost exclusively “from the family or from individual charity, while in northern societies this was largely accomplished through public and private institutions,” and that in Mediterranean Europe the number of publicly or privately funded homes for the elderly remains very small compared to the north: “recent increases everywhere in the demand for this type of residence notwithstanding, there is no indication of a reduction of these divergent residential patterns in contemporary societies” [Reher, 1998: 209-210]. [3]

6It is tempting to extend these arguments to a comparison between the two shores of the Mediterranean and to use nursing homes as an indicator of cultural distance or proximity, but we must first wonder whether the two shores are facing similar demographic challenges and the need for such institutions is therefore comparable in this respect. When it comes to ageing, it is in fact quite common to stress the differences (instead of looking for commonalities) between a demographically old northern shore of the Mediterranean and a much younger southern shore. However, the trends that have emerged in the past decades demonstrate that this is a misconception and that a new demography is unfolding: the countries on the southern shore are ageing very rapidly and they will increasingly resemble those on the northern shore because of the combined effect of fertility decline and gains in longevity [Courbage, 2013; Matthijs et al., 2015]. Very significant transformations can also be observed in the realm of marriage and the family: although consensual unions are rare or non-existent, and marriage therefore retains its centrality, ages at marriage are rising both for men and even more for women [Singerman, 2011], and everywhere extended multi-generational households are declining and giving way to nuclear households which are partly associated with changing ideals about family life and partly a response to internal and international labor migration [Hopkins, 2001; Yount and Sibai, 2009: 290-297]. As has been neatly shown [Boggatz, 2011], on the southeastern rim of the Mediterranean the estimated need for elder care, and homes for older persons, is thus quickly approaching the levels to be found on the northern shore.

Nursing homes: institutionalization and its discontents

7In a pioneering article published in the early 1980s, the American anthropologist Andrea Rugh [1981: 203] bluntly stated that “institutionalized orphans and old people are two categories of people that, strictly speaking, should not exist in Arab society if the popular notion is correct that Arab family group responsibility is all pervasive.” Yet, as her own study of Egypt shows, they did exist and in some cases they also had a rather long history. Expatriate communities established the first homes for the aged in Egypt in the last decade of the nineteenth century, mostly to support elderly nationals stranded in a foreign country with no relatives to provide care. A second wave of institutional development came in the 1930s with the foundation of nursing homes by local Christian and Jewish communities, and a third one in the 1960s, when new homes were established with the sponsorship of Islamic and general societies of unspecified affiliation and, to a very limited extent, of the government [ibid.: 221-224]. In the late 1970s, at the time of Rugh’s research, only 28 homes for the aged were registered with the Ministry of Social Affairs. In the past four decades this number has more than quadrupled, yet the places they can offer to the vastly augmented elderly population of Egypt are hardly sufficient: in 2008 it was estimated that there were approximately 365,000 old people needing some kind of care, but only 4,000 places were available. What is more, these institutions are overwhelmingly concentrated in Greater Cairo and Alexandria and there is still a marked difference, as Andrea Rugh had already noticed, between charitable institutions for the poor and better-quality homes for those who can afford to pay [Boggatz, 2011: 16-18].

8The picture does not look dramatically different in the other countries on the southern, or indeed, on the northern, shore of the Mediterranean. The data are fragmentary but eloquent. Kronfol and Sibai [2013: 338] estimate that fewer than 1 per cent of the elderly in Lebanon are institutionalized. Even lower proportions are reported for Tunisia by Gouiaa and Sibai [2013: 354], where retirement homes are exceedingly rare and accommodate only 0.07 per cent of the elderly population [4]: “This is much lower,” they remark, “than the prevalence rates of institutionalization in Europe and the Western world.” Still, figures for southern European countries are not a great deal higher. According to the 2001 census, fewer than 1 per cent of the elderly population in Greece was institutionalized at the time [Moukanou, 2009: 10]. Although marginally higher in Spain and Italy (in the region of 2-4 per cent), they are far lower than in northern Europe and have increased only slightly since 1990 [Da Roit, González, and Moreno, 2013: 155-156].

9The reasons accounting for such a different development as compared to northern Europe appear to be quite similar on both shores of the Mediterranean. The reasons suggested for Lebanon, namely that “the prevailing caregiving role of the family members in Lebanon contributes to delaying or lowering institutionalization rates, reducing expenditure on formal long-term care services” [Krobol and Sibai, 2013: 338] are echoed in Greece, where the low rate of institutionalizations is primarily attributed to the importance of family ethics and secondarily to the shortage of places and their uneven distribution within the country and to the low quality of the provided services [Moukanou 2009: 10].

10Institutionalization, however limited, nonetheless exists. The question is why? Interesting evidence comes from qualitative research conducted in Cairo by Sinunu, Yount and El Afify [2009] and by Boggatz [2011]. Both studies confirm that placing an older parent in an institution is generally stigmatized and considered a last resort in the case of frail or cognitively impaired family members. A 39-year-old woman who institutionalized her father reported to Sinunu and her colleagues that, “We started to think about a hospital. But we didn’t make the decision until one day he developed this semi-coma…” Another woman said that she resigned herself to institutionalizing her father when it became clear that his life “was endangered in some of his activities or behaviours, for example […] he started going out in the street and losing his way home” [Sinunu, Yount, and El Afify, 2009: 70].

11Oral testimonies collected by Boggatz also reveal gender differences in caregiving decisions, however. Men tended to present them as individual decisions that they had made, whereas women saw them as family decisions that they had accepted. Boggatz also reports the interesting case of a 70-year-old woman who assured the interviewer that the decision to enter a nursing home was her own, against her son wishes:


I tricked him. I told him I was going to a friend’s, and I had a small bag, so he drove me here [to the nursing home]. When he was coming in here he told me, “This is an old people’s home!” I said, “Yes,” and he got angry and asked me, “Did I make you upset? Is there anything I’m not doing for you?” I said no, and so he cried and got really sad. He told me that when he wants to get married, he can’t tell his wife or her family that his mom is in an old people’s home. This would mean that he was not a good son. [Boggatz, 2011: 75]

13This is a revealing inversion of the story told in the Italian film, but the message is very much the same: placing one’s mother in a nursing home is morally disreputable. The question remains, however, of how ageing should be faced.

14For older persons who lack family support and cannot afford to do otherwise, Boggatz [2011: 19] describes a practice that exists in Cairo that allows the elderly to receive outside support from groups of volunteers who perform home visits. This service is promoted by the Coptic Orthodox Church to support needy members, but charitable organizations can provide similar services for Muslims. Boggatz emphasizes, however, that this form of assistance is primarily limited to emotional support. Interestingly, this is reminiscent of the forms of volunteering in Milan described by Muehlebach [2012], who conducted an ethnographic study of Catholic and lay associations whose principal mission was supporting elderly people in need. Muehlebach selected Italy for her research because no other country in Europe relies so extensively on volunteer labor, primarily to compensate for a weak welfare state. Her findings reveal that the role of these associations should not be underestimated, but their practical impact ultimately appears less significant than their ideological message. Indeed the very fact that volunteers in Milan as well as Cairo refrain from providing significant material care suggests that their work cannot pretend to meet the enormous eldercare needs of Italian—or Egyptian—society. As a consequence, eldercare remains primarily a family responsibility in both countries. Families, however, are undergoing rapid change and the relationships between family members—and especially decisions surrounding care—are in the process of being renegotiated.

The “nuclearization” of households: a Mediterranean pattern?

15There is a widespread assumption that cohabiting with elderly relatives is the most effective way of helping them. The historian Sabine Huebner [2011], for example, recently advanced a sweeping argument that the extended family has been a long-standing unifying feature in the whole Mediterranean area and that its primary raison d’être was precisely the elder care and support that it was uniquely able to provide through co-residence. It has recently been argued, however, that claims that the extended family is the dominant model throughout the Mediterranean region are unwarranted. Indeed, it is known that nuclear-family households have historically prevailed in southern Portugal, Spain, and Italy, and several parts of Greece at least since the early modern age [Sacchi and Viazzo, 2014: 237-241]. Nevertheless, measuring co-residence—particularly from the privileged vantage point of the living arrangements of the elderly—is definitely a worthwhile exercise.

16Beginning on the northern shore of the Mediterranean, we find that the level of co-residence is currently markedly higher than in northwestern Europe, [5] although it has declined significantly in recent decades, in keeping with the decline of extended families. Particularly detailed evidence regarding this pattern is available for Italy. A study based on census data by the sociologist Marzio Barbagli [1984: 113-124] reveals that in 1951, the percentage of extended-family households [6] in Italy as a whole was approximately 22 per cent, and that nearly one third of the Italian population lived in multi-generational households. However, in the regions of central Italy, where sharecropping favored the formation of households approaching the “patriarchal” ideal-type in which married sons stay with their parents, the proportion of people living in extended families approached or even exceeded 50 per cent. At the opposite extreme, in southern Italy, extended families accounted for just fewer than 20 per cent of the population, with northern regions somewhere in between. Thirty years later, the percentage of extended families had fallen by half, and the importance of nuclear families had correspondingly increased. Still, examining the living arrangements of the elderly in 1981 reveals that in the central regions, 60 per cent of widowed elderly people lived in extended families, and, interestingly, that in the southern regions. These percentages indicated a definite tendency to reintegrate frail or vulnerable elderly relatives into the nuclear family [Barbagli, 1997: 38].

17Since 1981, the “nuclearization” of the Italian family has continued, with the percentage of single-person households rising steadily, largely reflecting a growing tendency for widowed elderly people to live on their own. The national census in 2011 revealed that 38.4 per cent of people over 75 were living in single-person households. [7] This appears to indicate an imminent convergence with northwestern Europe. This conclusion should be resisted, however, because is has become apparent that in Italy, the old co-residential model is in fact being replaced by new patterns of close residential proximity. In Italy, children may well establish separate and independent households and be less likely to “absorb” widowed mothers and fathers into their households, but the generations tend to continue to live near each other or even in the same building. [8] This tendency is not confined to Italy, however. International comparisons indicate that the same is true in the other southern European countries, to a far greater degree than in the north. [9] Residential proximity is thus emerging as a significant difference between Mediterranean and northwestern Europe [Viazzo, 2013: 62-65].

18On the southern shore, detailed data are available particularly from Egypt, where in 1995, the picture looked uncannily similar to the one emerging for Italy in 1951—according to the Egyptian Demographic and Health Survey (EDHS), which covers both urban and rural administrative regions. Although three-fourths of Egyptian households were nuclear-family households and only one in five was an extended-family household, extended living arrangements accommodated nearly one-third of all the household population [Khadr and El-Zeini, 2001: 147-148] [10]. No less interesting is the comparison between the 1907 and 2000 censuses of Istanbul recently carried out by Duben. In 1907, approximately two-thirds of the elderly persons aged 65 years or more lived in extended living arrangements, a century later, this proportion had halved to 32.8 per cent. In the same period, those living alone nearly doubled, from 8.1 to 15.7 per cent, while the proportion of the elderly living in nuclear families had skyrocketed from 18.9 to 48.4 per cent [Duben, 2013: 28-34, 2016: 159].

19As in Italy and the other southern European countries, the growing nuclearization of Istanbul’s households would thus seem to expose the elderly to what Laslett [1988] called “nuclear hardship,” i.e., the increased risk for old people of finding themselves without familial support at some stage of their life-cycle and in a condition of actual or potential hardship that is likely to be most acute for those who live alone. Indeed, Duben observed that in Istanbul, an all-important implication of the process of nuclearization is that in 2000, “at the age of eighty to eighty-four, more than one-third of women were living alone or with a non-family member.” However, he immediately adds that we must “take what is defined as ‘living alone’ in the eyes of the census taker with a grain of salt when we examine the actual experience of the elderly in Istanbul” [Duben, 2013: 36-37]. The qualitative evidence that he has amassed, particularly through interviews, shows the significance—in Istanbul as well as in other countries on the southern shore of the Mediterranean [Yount and Sibai, 2009: 291-292]—of proximate family living as a powerful adaptive strategy favoring a dense web of exchanges across households. But in addition to residential proximity, other family strategies are also at work.

Family bargains: co-residence, near co-residence, and residential proximity

20Levels, trends, and patterns of intergenerational co-residence have been investigated, especially in the countries on the southern shore of the Mediterranean, using sophisticated socio-demographic and epidemiological studies based on EDHS and comparable survey techniques. It is worth remarking that the more significant studies take the influential notion of patriarchal bargaining proposed by Kandiyoti as their starting point, which is based on her contention that “a woman’s life cycle in the patriarchally extended family is such that the deprivation and hardship she may experience as a young bride are eventually superseded by the control and authority she will have over her own subservient daughters-in-law” [Kandiyoti, 1988: 279]. The cyclical nature of women’s power and their anticipation of inheriting the authority of senior women thus encourage the internalization of patriarchal ideology by the women themselves, and subordination to men is offset by the control that older women exert over younger women. Women are aware, however, that they have access to old-age security through their married sons and the care of their daughters-in-law. Ensuring their sons’ lifelong loyalty thus becomes an enduring preoccupation and a central issue in a further bargaining process between genders and generations.

21Yount [2005; 2009] converted Kandiyoti’s ideal-typical construct into a testable statistical model in order to study intergenerational co-residence in Egypt. Her findings confirm that residing with married or unmarried sons is older adults’ preferred living arrangement, whereas living with daughters, although less common, also occurs but at lower rates. She also found, however, that older women live without spouses but with married and unmarried children at higher rates than older men and, even more interestingly, that living with sons-in-law, an “alternative” living arrangement that is extremely rare among men, is not uncommon for older women. Yount interprets this difference as an indication “that ‘patriarchal bargaining,’ or women’s exchange of kin-keeping tasks for protection from kin may give women greater access to care through normative and alternative intergenerational living arrangements” [Yount, 2005: 156]. Because of several signs pointing to a lower “degree of patriarchalism,” Yount and her colleagues chose to use Tunisia as grounds for comparison with Egypt. Their comparison reveals that families are the main source of support for older adults, but that patterns of co-residence in the two settings are indeed different. In Tunisia, the trend towards increased nuclear living arrangements appears more robust than in Egypt, but this trend is also more balanced by trends to reside in proximity to kin and to visit them frequently [Yount and Agree, 2004: 129]. According to the authors, this pattern indicates a transition from co-residence to spatial proximity that is reminiscent of trends observed on the northern shore and, as noted earlier, in Istanbul.

22The diverse bargaining processes under way in changing “patriarchal” families [Moghadam, 2004] suggest that the very notion of co-residence needs to be rethought and qualified. Multi-sited ethnographic studies of the spatial and relational arrangements of transnational migrant families that have migrated from rural northern Egypt to Italy offer some useful insights into these processes [De Gennaro, 2017; Ferrero, 2018]. This migration route has a several-decades’ history and has proven beneficial for many families, although the adaptation has been affected by the recent economic crisis. The remittances generated by migration have redrawn the landscape and the relational geography of these migrants’ villages of origin. The mud and straw houses (dār that used to shelter local extended families have been replaced by multi-story structures (bēt il-’ā’ila) that house nuclear families headed by a married son—or in which each conjugal couple still formally belonging to the extended family has its own apartment (shaqqa).

23These vertically-extended family buildings provide a marked example of “near co-residence” [Szydlik, 2016: 94] that enables old couples, their married sons, and their daughters-in-law not only to live in the same house but also to continue to share crucial spaces and activities such as eating together, shopping, and working in the fields. It would therefore be a mistake to conclude that these new buildings and the process of nuclearization that they have accelerated have caused local extended families to collapse. Instead, ethnographic observation has shown that migration and remittances have decisively contributed to novel bargaining processes within the patriarchal social space.

24The transition from dār to bēt il-’ā’ila epitomizes these newly negotiated solutions, which reflect a situation that is located between a search for autonomy and persistent mutual dependence. Building a new apartment often involves tense negotiations between a father—who owns the land on which the house has been erected and feels his patriarchal authority threatened—and his migrant sons who are seeking to gain autonomy from their father and become independent heads-of-household in their own right [De Gennaro, 2017: 117-136]. Migrants’ left-behind wives enjoy a higher degree of autonomy and privacy in their own apartments. Because of their husbands’ absence, however, they may be subject, even if they “statistically” live in a separate nuclear family, to even more binding obligations. Providing care to parents-in-law or simply moral subservience to their authority are potentially onerous consequences of their left-behind status that can affect not only those who are physically “near co-resident” but the entire transnational family. Indeed, there are documented cases of women who joined their migrant husbands in Italy but were compelled to abruptly return-migrate in order to provide care for parents-in-law who had remained alone. Ferrero [2018: 178] reports that “the management of everyday life radically changes once the parents-in-law have died: meals are more frequently eaten in the apartments, shared spaces shrink, sisters-in-law must no longer divide up the household chores in the common parts of the house and family hierarchy shifts in their favor.”

25Somewhat similar processes are under way on the opposite shore of the Mediterranean in central Italy, where the decline of agricultural sharecropping in the mid-twentieth century caused the collapse of large “patriarchal” families and triggered a process of nuclearization of the households. However, as Grilli [2008] emphasizes, the image of a “structural thinning-out” of the family as an obvious consequence of nuclearization, conveyed by demographic sources and statistical representation, contrasts with the breadth and thickness of the relational networks that ethnographic research reveals. In many rural parts of central Italy, one rather encounters delicate compromises between a “modern” search for autonomy and individuality and “traditional” belonging to kin groups which no longer live and work together but continue to share spaces as well as activities and tasks such as meals, domestic chores, the care of children, and eldercare. As a result of explicit and implicit negotiations, “time after time houses have been enlarged, readjusted, subdivided into several apartments in order to meet new requirements.” This subtle bargaining process has enabled them to continue to “provide family spaces where at least two, three or, in some case, even four generations live much of their lives” [Grilli, 2008: 144-146].

26These ethnographic sketches provide evidence of a “Mediterranean style nuclearization,” although they are typical of rural areas. The question of how urban contexts are responding to these same pressures has been addressed by a number of studies. Although the prevalence of nuclear families has been documented in Cairo since the Ottoman census of 1848 [Fargues, 2003: 38], twentieth-century industrialization and urbanization in Egypt have spurred internal migration and promoted the settlement or formation of an ever-growing number of nuclear-family households in the cities. Even in urban contexts, the extended family has nevertheless remained a reference model for many social groups and classes. Ethnographic studies in Cairo in the 1980s by Rugh [1984] and Singerman [1995] confirmed a clear tendency for relatives to reside in separate nuclear households but in close proximity in the same neighborhood or the same blocks of flats that include brothers, sisters and cousins. This finding remains true today. Not only in rural areas, but also in cities, one often encounters family-owned apartment buildings in which “an older couple and their married children live in what the census shows as separate, nuclear-family households, but which are separated only by a hallway or staircase” [Cuno, 2008: 208]. [11] In recent years, however, a housing scarcity and increasing costs associated with marriage have slowed this tendency to live in close proximity, paradoxically encouraging a return to co-residence by forcing young couples to begin married life in the home of the groom’s family.

27The resulting pattern contributes to “extending” families in urban contexts that have shared a long history of nuclear-family household dominance [Singerman and Ibrahim, 2001: 103; Yount, 2005: 156; Cuno, 2008: 208; Singerman, 2011: 70-75]. There may be a silver lining, though, as “in addition to enabling a young couple to begin married life without having to delay for years while working to accumulate the cost of an apartment,” this practice, as informal observation suggests, “also has the advantage of providing a couple with assistance in childcare and enabling them to look after elderly parents” [Cuno, 2008: 212].

28Indeed, intergenerational help is the first reason mentioned as an explanation for the fact that parents and children in southern Europe, where state support is weak, tend to live close to each other. In particular, residential proximity is commonly cited as a social device that enables “absorbing” the elderly into the family while preserving a degree of separateness and independence between generations. This solution allows a remarkable degree of flexibility and fosters cultural adaptation to demographic and social changes. Still, even residential proximity may not be enough to cope with elder care needs, and supplementary forms of assistance are often required. In answer to this need, a new form of assistance has recently spread among countries on the northern shore.

“Like a daughter”: homecare and kinning

29Another example of flexibility that marks a social and cultural boundary between southern and northern Europe is the dominance in southern Europe of a pattern of elder care (often referred to in the sociological literature as “Mediterranean”) consisting of hiring live-in elder-carers who are primarily migrant women. This arrangement has become so widespread that three Italian economists have spoken of “a transition from a ‘family’ to a ‘migrant in the family’ model of care” [Bettio, Simonazzi and Villa 2006: 272], a felicitous formula often quoted in the literature [Moukanou, 2009: 8; Climent, 2011: 163; Weicht, 2015: 59]. According to Gal [2010: 293], this form of family-funded elder care is developing in every country in what he refers to as “extended family of Mediterranean welfare states,” including Portugal, Spain, Italy, and Greece, as well as Malta, Cyprus, Israel, and Turkey. It remains to be seen whether this pattern, which is part of a complex familistic transnational system, will extend—or is already extending itself—to countries other than Israel and Turkey on the southeast shore of the Mediterranean.

30In a recent overview of elder care in Arab countries, Sibai and Yamout [2012: 72] assert that in recent decades “privileged families from middle- and high-income countries have increasingly opted for a new form of in-home care given by full-time live-in migrant workers, mainly from southeast Asia and Africa. These migrants, playing the role of both housemaids and companions, provide long-term care to older people who are dependent on help in daily living.” Some of these Arab countries adjoin the Mediterranean Sea. In Cairo, and more broadly in Egypt, for example, Boggatz [2011: 18-19] has observed salaried caregivers living in elderly people’s homes. Unfortunately, the typically unofficial nature of this category of employment makes it difficult to determine how widespread it is or the origins or socio-economic status of these live-in carers or those who employ them. Boggatz believes, however, that the phenomenon is not yet widespread and involves only a tiny fraction of the population. Sibai [2009] believes, on the other hand, that the employment of migrant labor for domestic work in Lebanon already represents a core dimension of elder care. In 2004 live-in caregivers assisted at least 5 per cent of Lebanon’s older adults. However, although this form of support retains a “family orientation” for elder care, she considers that besides lacking formal qualifications, migrant caregivers “lack moral commitment or filial attachment to the older person,” increasing the potential for financial as well as emotional abuse of the elderly by domestic workers [ibid.: 2-3; Sibai and Yamout, 2012: 72].

31These are among the concerns raised by what Buch [2015: 285] has labeled the “commodification of intimacy.” The risks of exploitation and abuse are undeniable, and it is also clear that the relationship between a care recipient and a paid care provider stems from a contract that is inevitably affected by the law of supply and demand. Still, we cannot ignore a growing body of research suggesting that the domesticity inherent in the fact that migrant women care for the elderly inside their homes is spawning new forms of relatedness bordering on kinship. In a recent article, Micheli [2017] forcefully insists on the dissonance between the theory of commodification and exploitation of care workers and case studies that instead suggest that a work contract can also be a kind of port of entry to paid but not wholly commodified work. In his view, living together is a catalyst that can trigger what social psychologists call “high-intensity affective relationships.” This claim is corroborated by an extended fieldwork study among caregivers from the Philippines in Israel. Indeed, Mazuz [2013: 127-128] emphasizes the contrast between Israeli caregivers in nursing homes and Philippine workers who reside in the older persons’ homes and provide round-the-clock care. Inside this cocoon, she remarks, “performing mundane and intimate life activities entails ongoing close physical interactions,” bodily forms of care that result in the emergence of a “familial dyad” that is typically accompanied by the use of kinship terms between caregivers and their eldercare recipients.

32A similar process of “becoming relatives” has been noted in other ethnographic contexts, not surprisingly in southern Europe, where live-in caregiving has become particularly widespread. Some refer to the creation of “fictive kinship” [Weicht, 2015: 58-65], while others prefer to borrow Howell’s [2003] concept of kinning, avoiding the implicit comparisons between “true” and “less true” forms of kinship. Howell’s term also appears more suitable to the processual nature of the protracted interaction through which an employment relationship can gradually be transformed into a different kind of relationship. A well documented study by Baldassar, Ferrero, and Portis [2017: 524] conducted in northern Italy suggests that these processes can extend to care recipients’ children and other relatives (or even members of caregivers’ transnational families). These transformed relationships are often associated with familial expressions or statements—“For me she’s more like a daughter than an employee,” and reciprocally: “I feel like I’m looking after my mum and so it doesn’t feel like work”—and also with familial athmospheres. As the daughter of one eldercare recipient told the authors of this study: “There are certain scenes that stay with me. I remember one when I dropped by after work and I found them [father and care worker] sitting at the table with a spoon each, eating from the same big ice-cream bucket. They were just eating happily together.”


33This article has primarily been based on comparisons between Italy, the southern European country with which the authors are most familiar, and countries situated along the southeastern rim of the Mediterranean, particularly Egypt, due to the availability of abundant demographic, sociological, and ethnographic data. Additional reports from other Mediterranean countries appear to confirm that evidence from Italy and Egypt is fairly representative of the entire region.

34It took its start from a comparison between attitudes towards retirement homes revealed by two vignettes in which an Italian “monster” tricks her mother, and an Egyptian mother misleads her son. Although such attitudes continue to be present, it is also clear that in recent decades most European countries have witnessed a growth in deinstitutionalization policies, with a corresponding increase in home-care, variously known in the different countries as aide à domicile, servizi domiciliari, Heimhilfe. A notable north-south gradient, however, reveals that home-care coverage rates range from 20 per cent in Denmark to 3-4 per cent or less in Spain, Italy, Portugal, and Greece [Da Roit, González and Moreno, 2013: 155-156]. Equally significant, despite the pronounced shift in northern countries towards external assistance in home-based eldercare, significant differences persist between the domiciliarity of public home-care services and the domesticity of care provided by live-in caregivers in southern Europe, where welfare regimes remain fundamentally familistic.

35There is broad agreement across research studies that moral obligations continue to retain considerable power in the Mediterranean. Along the southeast shore, “patriarchy may be in crisis, but family ties still matter” [Moghadam, 2004: 156], and in southern Europe, powerful intergenerational obligations between parents and children persist [Viazzo and Zanotelli, 2010]. Sinunu, Yount, and El Afify [2009: 71] correctly argue, however, that, “although norms of obligation among kin remain strong, they are evolving to fit a setting that has changed markedly in the last 30 years.” The key term that Sinunu and her colleagues use to describe this evolution is “reinterpretation,” which is also a central notion for Allen, Bliezner, and Roberto [2011]. These authors provide helpful theoretical tools for examining the ways in which families are “extended” through processes of kin reinterpretation that include those described here. Old forms of relatedness such as co-residence continue to play major roles as the region’s families face the challenges of old age, but they are complemented or even superseded by relatively recent phenomena such as “near co-residence” and residential proximity. Entirely new arrangements such as live-in homecare have also experienced important growth. The evidence surveyed in this article suggests that the resilience of the family as a welfare agency—or better, of a familistic ideology combined with an ability to “extend” families through new forms of relatedness—arguably constitutes a unifying trait throughout the Mediterranean region. This development could potentially have alarming long-term consequences or perverse effects by giving cultural legitimacy to the ever-shrinking state intervention. ■


  • [1]
    It is worth noting that at the Malta conference France tended not to be included in the Southern European or “Mediterranean” grouping of Greece, Italy, Portugal and Spain since differences from an institutional point of view looked noticeable enough to suggest such a separation. However debatable, this taxonomy tallies with the propensity of the anthropological literature [see already Anderson, 1973: 98-100] to exclude France from Mediterranean Europe and group it with Western European countries.
  • [2]
    “Nursing home” is used here and throughout the article as broadly synonymous (and interchangeable) with such terms as “old age home,” “elderly care home” or “residential home” to designate all types of residential care for elderly people. It is therefore meant to correspond to casa di riposo or casa per anziani in Italian, hogar de ancianos in Spanish, maison de retraite or maison de repos in French, etc. It should be noted that “nursing home” is sometimes used in the international literature to designate institutions providing elderly people with high levels of nursing and medical care 24 hours a day, as different from old people homes which offer lower levels of care. As shown by a comparative study [Ribbe et al., 1997], twenty years ago facilities that met this strict definition of “nursing home” were especially numerous in such countries as the United States, Denmark or Iceland, while they were totally absent in France (where their number has, however, grown in the past two decades); other countries investigated lay somewhere in between.
  • [3]
    Difficulties in estimating rates of institutionalization may sometimes originate from variations in the interpretation of the definitions of nursing homes and residential homes (see note 2 above), but these semantic differences cannot explain the very marked differences between the northern and southern parts of western Europe.
  • [4]
    The institutionalization rate is very low also in Turkey: in 2012, in the whole country there were only 180 elder care facilities serving 12,000 individuals [Duben, 2013: 33], out of a total elderly population (65 +) of nearly six million.
  • [5]
    The results of the Survey of Health, Ageing and Retirement in Europe (best known as share) showed in 2004 that 23.2 per cent of Italian and 33.9 per cent of Spanish respondents in the oldest age group (80 +) lived with a child, compared to only 1.3 per cent in Sweden, 3.7 per cent in Denmark and 8.1 per cent in France [Börsch-Supan et al., 2006: Table 4A11].
  • [6]
    What we call here “extended family” encompasses (following Barbagli [1984]) types 2, 4 and 5 of the classic typology devised by Eugene Hammel and Peter Laslett [1974].
  • [7]
  • [8]
    In 2003 nearly 60 per cent of elderly widows and widowers living alone resided either in the same building with a child (25.5 per cent) or within 1 km (31.4 per cent), and very similar proportions were found for old couples in “empty nest” [Viazzo and Zanotelli, 2010: 73-78; see also Börsch-Supan et al., 2006: Table 4A11].
  • [9]
    share data are highly revealing: In 2004 the proportion of the elderly 80 years or older residing either in the same building with a child or less than 1 km from their nearest child was 43 per cent in Spain and 45.4 per cent in Greece, compared to 23.8 per cent in Sweden, 18.2 per cent in Denmark and 24.4 per cent in France [Börsch-Supan et al., 2006: Table 4A11].
  • [10]
    The household typology adopted in this survey [Khadr and El-Zeini, 2001: 147] is very similar to the one used by Barbagli [1984] in his reworking of Italian census data and also by Duben [2013] in his study of Istanbul mentioned below.
  • [11]
    Duben [2013: 38-42] documented similar cases of “near co-residence” in the same building in contemporary Istanbul. Of special interest is also a survey conducted in 1999 in the West Bank and Gaza by the Institute of Women’s Studies at Birzeit University, which showed that about three quarters of Palestinian households were nuclear, but also that the overwhelming majority of households living in apartments or attached dwellings shared these residences with relatives [Johnson, 2006: 92-94].

Families and the Elderly along the Shores of the Mediterranean: Old and New Forms of Relatedness

The ageing population is posing increasingly similar challenges to the societies on both shores of the Mediterranean, where families remain the primary welfare agencies. The socio-demographic and ethnographic evidence surveyed in this article reveals that although old forms of relatedness such as co-residence in extended families continue to play a role, they are complemented by coping strategies in which a familistic ideology favors the “extension” of families through new forms of relatedness ranging from close residential proximity between children and parents to live-in homecare where domesticity may catalyze kinning processes between elders and their caregivers.


  • Ageing
  • Mediterranean
  • Co-residence
  • Live-in homecare
  • Relatedness

Familien und ältere Menschen auf beiden Seiten des Mittelmeers : alte und neue Beziehungsformen

Das Altern der Bevölkerung stellt zunehmend ähnliche Herausforderungen für die Gesellschaften auf beiden Seiten des Mittelmeers, wo die Familie immer noch eine wichtige Rolle im Bereich des Sozialschutzes spielt, dar. Die soziodemografischen und ethnographischen Daten, die in diesem Artikel untersucht werden, zeigen auf, dass alte Formen der Beziehung, wie zum Beispiel das gemeinsame Wohnen in Großfamilien, immer noch eine Rolle spielen. Sie werden ergänzt durch Strategien der Anpassung, in denen eine familiaristische Ideologie die „Erweiterung“ von Familien durch neue Formen der Beziehung fördert, die von der wohnlichen Nähe von Kindern und Eltern bis hin zur häuslichen Pflege reicht. Die häusliche Pflege kann einen Prozess der Eingewöhnung zwischen älteren Menschen und ihren Betreuern katalysieren.


  • Altern
  • Mittelmeer
  • Gemeinsames Wohnen
  • Häusliche Pflege
  • Relationalität

Familias y personas mayores en las zonas costeras del Mediterráneo : antiguas y nuevas formas de relacionalidad.

El envejecimiento de la población plantea retos cada vez más parecidos entre las sociedades situadas a cada lado del Mediterráneo, donde la familia es aún la protagonista principal de la protección social. Los datos sociodemográficos y etnográficos examinados, en este artículo, demuestran que las antiguas formas de relación, como la convivencia en las familias ampliadas, todavía juegan un papel. Estas se completan con estrategias de adaptación en las que una ideología « familiarista » favorece la extensión de las familias, a través de nuevas formas de relación, yendo de la proximidad de residencia entre hijos y padres, hasta los cuidados a domicilio, donde el contacto doméstico puede catalizar un proceso de familiarización entre las personas mayores y sus cuidadores.

Palabras claves

  • Envejecimiento
  • Mediterráneo
  • Convivencia
  • Cuidados a domicilio
  • Relacionalidad


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Paola Sacchi
Università degli Studi di Torino
Pier Paolo Viazzo
Università degli Studi di Torino
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This is the latest publication of the author on cairn.
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