Comparative Tinkering with Care Moves
Peter A. Lutz
This chapter stems from my ethnographic study of senior home care in the United States and Sweden. In this study, I trace relations between people and technology as they come together in gatherings or ‘collectives’ (Moreira 2010) for care. Specifically, I am interested in how care moves with these collectives and generates interrelated consequences for the human and nonhuman actors concerned. However, these relational moves of care are rarely smooth. Instead, they comprise ongoing tensions or ‘frictions’ (Tsing 2005) which situate multiple acts of negotiation and ‘tinkering’ (Mol 2008; Mol et al. 2010). As such, ‘care moves’ offers a conceptual-empirical figure for fine-tuning ethnographic attention to care as a rough and tinkered process. It denotes an analytical emphasis on care as a mediating phenomenon interwoven with collective relations on the move, empirically and conceptually – entailing both effects and affects.
At the same time, I have not sought after a standardised social scientific comparison of two national healthcare systems, even though I worked in two different countries. Rather than rely on established categories, I remain interested in how to ethnographically tinker together – and thus care with – transnational comparisons in a more fluid or flexible manner. As such, I seek an experimental and ethnographic approach sensitive to the specific ways care moves with its collective relations.
Nevertheless, in my efforts, I have met numerous and unexpected hurdles. In this chapter, I revisit some of these challenges. They interrelate with informant or ‘emic’ comparisons about care and how it should move. These range from how to attend to mobility in and around the home, to future concerns including when to transfer into assisted living. My ethnographic travels between these different care moves led to perspectives that resist straightforward comparison. For instance, some seniors have family members nearby who help with home care, while others do not. Some have sufficient health coverage, while others struggle to find affordable good care. Some face serious health challenges that impede mobility and increase isolation, while others retain relatively good health. More importantly, care situations change dramatically in a single instant, and from one day to the next. If an older person falls, for example, it may dramatically alter the senior home care arrangements.
In this diverse field of care, certain comparisons suddenly seem unwieldy, while others become irrelevant or mundane. I find getting stuck in these comparative complexities akin to Donna Haraway’s (2008) notion of ‘staying with the trouble’. In other words, my efforts to compare became tightly connected with the troubles and rough moves of care that I encountered. Here, I have in mind a different breed of comparison, untethered from modes of comparison that solely adopt the standardised categories of a scientific repertoire. In this chapter, I set out to develop this approach as ‘comparative tinkering’.
Ethnography is central to this approach because it generates ‘passages’ to tinker with different comparisons of care moves. As such, ethnographic passages help ground comparative tinkering as a tool for mobilising social scientific insights. Like senior home care moves, comparative tinkering with ethnographic passages equates to rough, zigzagging, analytical moves. Michel Serres’ (1980) ‘northwest passages’ is a good analogy here.1 The difference is that my ethnographic passages entangle reflexive comparisons between careful doing and thinking. More generally, my comparative efforts relate to an experimental turn in social scientific methodology (Otto and Bubandt 2010; Lury and Wakeford 2012) and the interest in ethnographic transnational comparison.
Through my ethnographic passages – consisting of ‘field-desk relations’ (Strathern 1999) or ‘conceptual-empirical mixtures’ (see Gad and Ribes 2014) – a series of questions emerge that ground this chapter. How, for instance, do complex care moves compare in senior home care? Similarly, how do the subtle tinkering moves of care compare in a transnational analysis? How might social scientists make careful comparisons of others’ comparisons without losing sight of the messy work and moves of care itself? Moreover, how do such questions challenge what we deem to be ‘noteworthy’ comparisons – namely comparisons worth taking notes on in the field and tracing as valuable insights in scientific discussions? With these questions, I focus attention on how noteworthy comparison can entail travel worthiness, whereby comparisons with care move both empirically and conceptually.
The assertion that comparison resides in motion is relevant here, and relates to recent ideas in anthropology and science and technology studies (STS) about how to blend different kinds of scientific-informant, or etic-emic, knowledge relations. Work by Gergely Mohácsi and Atsuro Morita is exemplary. They focus on the interrelations between travel and transnational comparison and proffer the notion of ‘travelling comparisons’ (2013) as an experimental analytical approach. With this notion, they draw attention to the importance of mundane human and nonhuman movements that make and unmake similarities and differences in practice. For instance, in one account, Morita (2013a) traces how Thai workers compare Japanese-made cultivator blades that become tangled with Thai weeds when tilling the land. He shows how these machine-weed tangles situate Thai farmers’ and mechanics’ comparisons between their local work practices, their environments, and the Japanese-made machines, which the Thai import, modify, and copy. Morita explains:
In this context, the specific parts of the machine that caused the trouble – the blades entangled with weeds – generated a sort of comparative vision. The mechanics and farmers saw the weeds wrapped around the blades as a difference between the Japanese environment that the machine embodied and the actual environment in the farmers’ fields. In other words, the blades entangled with the weeds produced a double vision in which the Thai and the Japanese environments were seen at once through their difference (2013a: 235–6).
Thus, Morita argues that the coming together of heterogeneous entities – farmers, mechanics, engineers, blades, weeds, and so on – offers an opportunity to locate social scientific comparison in practice. Key in Morita’s analysis is the attention to others’ use of technology, and how machines present workers with the opportunity to generate transnational comparisons. For inspiration, Mohácsi and Morita also turn to Marilyn Strathern and others who argue for analytical experimentation in the relationship between emic and etic comparisons, and what some consider ‘lateral’ moves (Maurer 2005; Gad and Jensen, this volume).
Similarly, I hope to contribute to this way of rethinking the agency of social scientific comparison in relation to movement and transnational research, and between emic and etic concerns. Two of my previously published articles provide material for my deliberation. One article focuses on the movement of household clutter and technology in US senior home care (Lutz 2010). In the other, I centre on how healthcare technology helps generate different spatiotemporal ‘surfacing’ moves in Swedish senior home care (Lutz 2013). It is important to stress, however, that I sidestep transnational comparison in these publications. At the time of writing, I simply did not find what seemed like traversable ethnographic passages for a transnational comparison. As I indicate above, senior home care in both countries, and in its different situations, appeared undeserving of comparative travel.
With the idea of comparative tinkering in hand, here I retrace the potentials of comparison in these passages. This includes a search for links between my own comparisons and those of my informants. Drawing on ideas in anthropology and STS about comparison and human-nonhuman care, I tinker carefully with how care moves might inspire social scientific comparison in an ethnographic and transnational mode. As an experimental concept, comparative tinkering denotes the rough and uncertain process of mediating categorical differences to generate new comparisons, which link to how care moves in practice. Although this does not align with the usual notion of scientific comparison, I propose that it situates a significant comparative approach.
The literature on care in practice (Mol 2008; Mol et al. 2010) influences my thinking about careful comparisons as relational tinkering.2 Others have suggested similar terms. For instance, Jeanette Pols (2012) emphasises ‘fitting’, while Myriam Winance (2006) proffers ‘adjustment’. In Mol’s view, the aim is to find ways to study care ‘in and on its own terms’ to open up different ways of knowing what care is and evoke ‘what it is to hang together’ (2010: 265). I suggest that this also pertains to making scientific comparison work and move with care, and this entails accounting for the comparative practices of informants.
A team of Swedish care workers provide an apt example. One morning, over coffee, they explained their approach. With the increasing number of senior clients in their care, they decided to alternate their client rounds each week so that every worker could gain fresh knowledge about every senior’s changing situation. This approach made their work less monotonous. More importantly, it supported the collective decision-making about necessary adjustments to an individual’s care routine. ‘Otherwise’, they remark, ‘we have no real perspective’.
These multiple tinkering care moves – with its adjustments and ongoing comparisons – relates closely to my own reflexive efforts to comparatively tinker with ethnographic passages. In this way, I suggest that tinkering comparisons opens up possibilities to blur the distinction between emic and etic. Yet, the scientific literature often takes a different path by fixing its comparative categories. To exemplify this, next I review how the gerontological literature treats the transnational comparison of senior care in the US and Sweden. This will help to further orient the analytical challenges I found in my own work and motivate the notion of comparative tinkering, which I develop in the rest of the chapter.
Comparisons of Care
We should not compare US and Swedish geriatric services […] The cultures and healthcare systems are just too different to support meaningful comparisons.
– John Rowe (2011)3
There are many comparative studies of healthcare systems in the scientific literature. However, I only found a handful that explicitly compare the situation for older people who require home care in the US and Sweden. Why do some scholars apparently sidestep this transnational comparison? In the quotation above, Rowe indicates the issue of cultural and healthcare differences. Marti Parker echoes this point when she suggests that such a comparison risks absurdity, given the vast population differences in each country (2001: 86). Sweden is a country of more than 9.5 million, while the US population has reached 320 million (World Population Review 2014).4 In addition, some US seniors face extreme poverty, while there has been a lack of poverty among Swedish seniors since World War II (Parker 2001: 26). Parker also argues that these two countries historically represent ideological opposites in terms of welfare policies and services. For instance, Sweden traditionally has universal public healthcare, while the US typically adopts a market-driven model.
On the other hand, Parker considers how this comparison also makes sense. Both countries face welfare challenges linked to the changing demographics – so-called ‘population ageing’. Currently, people over the age of 65 make up 19% of the Swedish population and 14% of the US population (World Bank 2014). In addition, Parker argues that both countries increasingly adopt similar healthcare strategies. For example, in Sweden, there is a growing emphasis on decentralisation and privatisation, while initiatives like the Affordable Care Act – also known as ObamaCare – have increased the national regulation of healthcare in the US. In addition, there is a growing emphasis on targeted healthcare needs and evaluation, although each country has developed a different version (Parker 2001: 73). Parker concludes that this increasing ‘convergence’ of healthcare for seniors offers opportunities to learn from the successes and failures in each country (Ibid. 88).
Additional studies that follow this comparison include Adam Davey et al. (2005), Dennis Shea et al. (2003), and Dominique Wang and Christian Aspalter (2007). Both Davey et al. and Shea et al. compare ‘formal’ or paid home care – provided by professional care workers – and ‘informal’ or voluntary home care provided by family members or friends in each country. Here the label ‘Activities of Daily Living’ (ADLs) groups together a diverse and complex range of needs into a single category.5 These articles, based on statistical analysis, conclude that while there is some convergence between the two countries, Swedish seniors are more likely to find ADL support. This conclusion confirmed the authors’ initial assumptions that the Swedish system offers several advantages for seniors in comparison to the US.
In their article, Wang and Aspalter (2007) survey healthcare systems in several countries, including the US and Sweden. To achieve their comparison, they focus on a series of ‘healthcare indicators’ consisting of statistical economic data on national healthcare expenditures. Their article does not distinguish senior home care per se, but it does offer implications for its broader socioeconomic conditions. The authors conclude that market forces largely shape the inequalities of healthcare in the US, while the tradition of universal public healthcare (based on solidarity and a strong public sector) still plays a dominant role in Sweden. In other words, while these studies acknowledge the convergence to which Parker refers, they also agree that Swedish seniors typically enjoy better care.
What additional insights might we gather from this handful of studies in terms of social scientific comparison? For instance, at first glance, this lack of US-Sweden comparison might appear to suggest a knowledge gap. However, this is not so. Extensive scientific knowledge about the healthcare in each of these countries does exist. Instead, I venture that many healthcare studies bypass transnational comparison to focus on an individual national healthcare system and its policies. The assumption here seems to be that each national healthcare system operates within its own specific set of contextual arrangements, where practices in other countries are less relevant. Such an assumption echoes Rowe’s relativistic statement regarding how healthcare differences between these two countries still create the risk of an incommensurable – or ‘apples and oranges’ – comparison. One might also surmise that transnational comparison simply does not present the most fruitful or easiest path of study. However, institutions like the World Health Organisation (WHO), concerned with global health and research agendas, continue to engage with transnational comparisons to inform their recommendations. Perhaps the issue does not simply concern the possibility or absence of transnational comparison, but whether it produces noteworthy scientific knowledge towards a specific purpose. Yet, how is this achieved in practice?
This question relates to another important point about the use of standardised analytical categories for comparison. For instance, in the above studies, transnational comparisons of healthcare often stem from economic typologies such as ‘welfare’ versus ‘market’ systems.6 These combine medical terminologies to stake out the conceptual ground for transnational comparison. Examples here include: ‘convergence’ (Parker 2011), ‘ADL support’ (Davey et al. 2005; Shea et al. 2003), and ‘economic healthcare indicators’ (Wang and Aspalter 2007). This use of analytical categories for comparison is akin to the notion of a standard ‘comparator’ – a device for measuring the properties or performance of a system with comparison to an established standard. In other words, standard categories as comparators help generate links between the different national healthcare systems for transnational comparison. However, I wager that such standard comparators also sidestep the empirical complexities of how care moves. We might think of this as regionalising or ‘domaining’ comparison without magnification (Strathern 2004), especially in terms of how senior home care transforms with its movements in practice.
From one point of view, the notion of ADL support presents an exception in the sense that it supposedly relates more specifically to the practice of care itself. ADL is shorthand for bathing, dressing, mobility, toileting, and eating – basic activities that concern senior home care in practice. However, I suggest that grouping these different practices together under the term ADL support glosses over the important and ongoing situational challenges that emerge with care moves. For instance, in Davey and Shea, we do not learn how any one ADL plays out in practice, nor what challenges it surfaces. Instead, they emphasise percentile differences between formal and informal support in both countries, based essentially on an abstraction. Thus, I propose that even a term like ADL support can generate conceptual-empirical gaps that miss the pervasive, ongoing specificities of care and its comparisons. Senior home care remains rich with comparative variations that weave incontinence, disease, disabilities, local healthcare infrastructures, family members, and volunteers (or their absence). Perhaps comparisons of care can also include attempts to resonate with such complexities on the move.
To summarise, I have argued that perspectives akin to Rowe’s tend to consider the differences between senior healthcare services in the US and Sweden as too vast for transnational comparison. On the other hand, the studies I outline in this section challenge this perspective. Yet, to pursue their transnational comparison they establish comparative categories – or standardised comparators – that bypass the endless stream of generative frictions produced as care moves in practice. For instance, ADL support, as a standard comparator, does not necessarily bring the analysis any closer to the multiple complexities found in care, in or on its own terms (Mol 2008, 2010). This critique echoes other observations about how comparisons of healthcare tend to sidestep or ignore the complex tensions of comparison in practice (Langstrup and Winthereik 2010). Related arguments also stress the need to weave social scientific comparison with comparisons made in care, including particular and ongoing decisions about the doing of ‘good enough’ care (Mol 2002). My intention is not to dismiss the above comparative literature. Indeed, I agree with Parker that senior home care in the US and Sweden can offer valuable comparisons. However, might such comparisons do more, such as challenge the conceptual assumptions built into the standard comparators? Moreover, how might we pursue transnational comparisons that initially seem unworthy? What if we rethink the value of comparison as hedged in the uncovering of incommensurable gaps rather than trying to fill them? What kind of tertium comparationis – or comparative thirdness – might we need?
Such questions relate to Deville et al.’s (this volume) alternative notion of the ‘comparator assemblage’ that temporally surfaces as a hybrid mixture of people and things, including the researcher(s) in the doing of comparison. Likewise, Christopher Gad and Casper Jensen (this volume) propose the idea of ‘lateral’ comparisons that embrace non-hierarchical relations that reside in conceptual-empirical mixtures. These approaches set out to reject predetermined or standardised comparative categories, and instead accommodate comparison as a mutually transformative practice that runs in multiple directions.
Similarly, I revisit connections between my own comparisons and the comparisons I found other care workers making. By revisiting two of my earlier articles that sidestep transnational comparison, I aim to experiment with how ethnographic passages might open up new avenues for comparison that initially appeared jammed. In the same turn, I also expose not only my own social scientific authority, but also my earlier hesitations about comparison. This retrospective turn to tinker with comparative views equates to what Strathern (2011) has termed a ‘binary license’ – the privilege to anthropologically compare, through textual contrasts and bifurcations, the relative comparisons of different others. As such, my comparative tinkering relates to concerns about social scientific method as well as what counts as scientific knowledge. To preface this move, I next introduce the practical conditions of my study. This will help to further situate comparative tinkering as a generative and experimental approach.
Comparisons in Care
My fieldwork on senior home care in the US and Sweden grew from a larger European research project. The wider objective of this project was to inform the future design and development of ‘ambient intelligent telecare’ for senior home care. Ambient intelligence is a term that references the artificial capacity to sense and respond to environmental cues and human expectations, while telecare is a general term for technology that supports home care. This initial research sought to contribute ethnographic knowledge that could intervene with design assumptions about senior home care, and thereby support the robust design of such technology. As noted, I focused on the question of how care moves and the relational frictions that such moves generate in these two countries. Given the underlying concern with the social scientific comparison in this chapter, below I overview how the conditions of this research entangled my own comparative efforts.
Various interests in the project influenced the decision to pursue fieldwork in the US and Sweden. In part, these stemmed from the project’s organisation. The Dutch multinational hi-tech conglomerate, Philips Research, led the project, while the European Commission financed it.7 Both actors were interested in the development of technology to meet the challenge of population ageing. In addition, Philips had recently acquired a North American telecare business (Lifeline), which offers a popular emergency response service based on wearable wireless technology. The project’s assumption was that a comparative ethnographic study of senior home care in practice could inform the design of new healthcare technologies in North America and Europe. In addition, we assumed that my personal knowledge of Sweden and the US, based on previous time spent in each country, could ease the challenge of fieldwork access. Thus, practical considerations influenced the direction of my comparative efforts with senior home care.8
Yet, as my travels and collected materials accumulated, my certainty about a standard transnational comparison weakened. In the previous section, I outlined reasons why a transnational comparison appeared questionable. These include differences in how these two countries finance and manage senior home care. In my fieldwork, personal dynamics also played a role, such as the informants’ willingness to share their ‘moving’ stories about care. This mixed with my capacity to establish trust and rapport. At the same time, with each new situation, my uncertainties increased. There were endless complexities stemming from the shifting concerns about ageing bodies, relations to household clutter, and the different spatial-timings of senior home care.9 Emergencies like falling could introduce urgent comparisons between ideas about stable and unstable bodies. Other comparisons concerned seniors’ past and present conditions, as well as the direction that future care moves should take. Despite the project’s initial comparative ambitions, it was clear that a standard transnational comparison would face difficulty.
The actual routes of my fieldwork, interlinked with the wider national healthcare contexts, also influenced my ability to compare. For example, in the US, telecare users were my primary pool of informants. After a series of initial telephone screenings from a randomly compiled list of one hundred telecare customers living in Washington State, I selected seniors willing and interested to meet for face-to-face home interviews. After retracted interest and scheduling conflicts, I eventually met with approximately twenty seniors. These first-time meetings were usually one-on-one engagements with a senior informant. When available, a family member also joined. With six of these people, I carried out more extensive fieldwork engagements, including participant-observation in their home care activities. To complement these meetings and broaden the picture of senior home care, I also added interviews with home care administrators, nurses, and local senior healthcare advocates.
In Sweden, my fieldwork routes proceeded along different lines. Although private home care organisations are on the increase in Sweden, I felt I could reduce conflicts of interest by only recruiting in public home care organisations, rather than in privately owned home care businesses. In addition, with the absence of a customer database, I recruited my senior informants in person, in three municipal home care service organisations. After briefing the managers and their staff about my project, they agreed to identify senior clients whom they felt could best participate. Overall, health and mental alertness were among the factors the staff took into account.10 Once the seniors had confirmed their interest and availability, I proceeded in one of two ways. Either I contacted seniors myself for the initial interview, or I joined the care staff on their rounds to meet the interested seniors in person. The different needs each senior required, as well as the relations between seniors and their care workers, also influenced my ability to recruit. Seniors who had good relations with the care workers were generally more eager to participate. I observed well over forty home care situations and interviewed many of the seniors in these situations. Approximately half a dozen of these seniors I then met on repeated occasions. As in the US, these follow-up visits often provided opportunities for participant-observation.
The US fieldwork generally produced more individual accounts based on one-on-one interactions, while the Swedish ethnography favoured group interactions consisting of one-on-three (or more) encounters – namely a senior client, one or more care worker(s), and myself. These variations also linked with the differences in how these two countries organise senior home care. Thus, in the absence of Lifeline customers in Sweden, or public home care workers in the US, my ethnographic passages increasingly prompted the problem of incongruent comparisons. In turn, these tinkered with my own empirical-conceptual moves. This included the rethinking of key terms such as ‘senior’, ‘home’, ‘care’, as well as ‘technology’ – all of which enfolded vastly different heterogeneities.
This knotting together of ethnographic passages, including my scribbled field notes on how care moves, spurred numerous questions about which factors to compare, as well as how to compare, without losing sight of their complexities. Increasingly, I felt it necessary to sidestep my initial comparative ambitions. In retrospect, akin to Rowe’s view above, I had detoured around the challenge of transnational comparison in my analysis. The two published articles I discuss below, each focused on a different country, evidence this avoidance. In what follows, I revisit these articles and their ethnographic passages to reconsider ways to tinker with new comparisons. My ambition is not to smooth over the comparative frictions, but rather to experiment with how these might generate additional opportunities for social-scientific comparison.
Comparative Tinkering with Spatial-Timings
In ‘Surfacing Moves: Spatial-Timings of Senior Home Care’ (Lutz 2013), I argue for spatiotemporal differences in Swedish senior home care and develop the term ‘surfacing’ for this purpose. My article was an attempt to work through the distinction between subjective and objective time, which is pervasive in the social scientific literature. Inspired in part by Janelle Taylor (2005), and especially Bruno Latour’s (1997) ideas on spatial-timing, I consider how humans and nonhumans come together in care moves to generate multiple surfacings that challenge the subjective-objective distinction of time. I also consider the policies of time management in Swedish public senior home care. These policies set out to economise and standardise senior home care. However, I show how such policies add to the complexity of care and its spatiotemporal surfacing, which actors must tinker with to sustain good care.
Ethnographic passages, entailing the use of technologies for scheduling Swedish senior home care, ground this particular article. One example is how a scheduler interacted with her software using the finger-mouse to orient multi-coloured blocks on the computer screen. These blocks represent different spatiotemporal entities that she neatly ordered into rows and columns on the screen to determine the weekly home care schedule. This spatiotemporal surfacing connected care workers with different seniors and their needs. The scheduler translated these needs from several standardised entries, including ADL codes that index ageing body needs with the necessary days and hours of the week for care. Simultaneously, this same move triggered the programme to automatically calculate the necessary times and routes for each senior client. However, this formalisation of space-time was impossible without first transforming people and things into what Latour calls ‘intermediaries’ – entities that move other entities with little or no mediation or transformation.
This was no simple task, and required the scheduler’s comparative tinkering to make the different spatial-timings fit and travel. In part, the scheduler must select and compare several different resources. These comprised archive documents of past care schedules and consultations with the other care workers, as well as with the managers overseeing the care services. Of course, she also drew from her previous employment experience as a care worker. Sticky notes left by her colleagues, stuck to the edge of her desk and keyboard, were also of central importance. These notes concerned updates in the clients’ care routines. On any particular day, senior care needs could conflict with the planned home care routines. This might entail a rescheduled doctor’s appointment or emergency hospitalisation. Thus, when it came to the actual hands-on doing of care, workers must again tinker with the timing and spacing of care. For instance, I witnessed how care workers concealed their paper schedule, out of sight in a pocket or the car, when working directly with seniors. When I asked the care workers about this habit, they expressed concern that the schedule would distract the quality of attention they tried to give their senior clients.11
During the preparation of that article, I did not find what I felt was a comparable example in my US material. Organisational time management procedures were not clearly present in the relatively informal US senior home care I had witnessed. With more foresight, I speculate that I may have better aligned my ethnographic passages to enable such a comparison. For instance, had I worked with US home care organisations initially, rather than Lifeline customers, perhaps I could have discovered richer comparative opportunities between the US and Sweden. I also consoled myself with the knowledge that at its core, ethnographic fieldwork is often serendipitous and full of uncertainty.
It is clear to me now that I had adopted a relativist stance, akin to Rowe’s sidestepping of transnational comparison, when writing the article. Yet, I was never satisfied with this stance. I had the distinct sense that I had missed a comparative opportunity. Perhaps I had thrown out the baby with the bathwater and given the game of comparison away (Strathern 2002).
With the notion of comparative tinkering in hand, I want to now retrace my ethnographic passages to consider how my US informants also tinkered comparatively with the scheduling of home care. Several US seniors struggled to have their care needs met. John’s care situation offers one example.12 John was a ninety-four-year-old widower, former university adjunct, community leader, war veteran, and farmer. His wife had died several years earlier, but he still lived in the same house he designed and built in the 1950s. He had four children. His oldest daughter Julie was in her sixties, and the most active with his care. When I first met John, he was in the process of hiring a new care worker to help with domestic tasks and some personal care. His previous paid care worker, Anita, had been excellent. Anita had been on time, made good food, paid attention to detail, and enjoyed intelligent conversation. However, Anita was a student and found an opportunity to study abroad. Suddenly, John needed to find a replacement.
On a whim, without consulting Julie, he hired Candice from an ad in the local paper. Unfortunately, Candice was often late. Her cooking was bland. She was unorganised and uninterested in conversation. Candice also had the habit of bringing her four-year-old son with her. John allowed this, but he felt it interfered with his own care. John and Julie agreed that Candice was not working out. She could not compare with the standards Anita had established. However, they were stuck with Candice until they could find her replacement. In an effort to improve Candice’s performance and accountability, Julie created a weekly schedule which she charted on paper and posted on the refrigerator door in the kitchen. This schedule listed the meals and basic routine duties. While this device temporarily improved Candice’s performance, her care remained unsatisfactory. John and Julie therefore replaced Candice with Debbie.
Debbie was timely, meticulous, a good cook, and enjoyed conversation. Thus, she compared more favourably to Anita. In light of these improvements, John and Julie considered removing the refrigerator schedule. However, Debbie suggested that they upgrade it with an erasable whiteboard planner, which they did. This schedule-cum-planner eventually helped the three of them better coordinate important changes in John’s care. With Debbie’s input, this care technology now accommodated phone messages and other reminders about upcoming appointments that shifted the spatial-timings of John’s care. However, Debbie now incorporated the basic tasks into her daily work without reminders. This eliminated the need for the display Julie had first created for Candice. In this way, the scheduling of John’s care was made less visible, or what Latour would call a shift from mediator to intermediary.
What comparative insights emerge here? For one, Anita helped establish a rough standard of care, which John and Julie implicitly used to compare Candice and Debbie’s performance. While this was not a formalised procedure, it did ease comparative decisions about movements in care. Here too, the schedule-cum-planner played a decisive, comparative role. John and Julie had first implemented the schedule to better align Candice’s care moves with Anita’s version. Then, when Debbie offered John and Julie another point of comparison, their inclination was to remove the technology. Instead, Debbie proposed a modification to allow collaborative adjustments to John’s care. In this way, the relatively inflexible schedule became a more flexible and collaborative care technology, transformed with changing collective of care. Here too, I find a comparative link with how Swedish care workers hid the schedule from their client’s view to generate more attentive hands-on care. Thus, tinkering with the visibility of more formalised care scheduling procedures in both cases connects to the doing of attentive, if not good, care.
My intention here is to show how comparative tinkering with care moves in ethnographic passages can produce important transnational comparisons. These comparisons do not stem from pre-established standardised categories but rather from the effects of care moves with technology. Starting with a curiosity about how spatiotemporal differences surface in Sweden, I employ a binary license to comparatively tinker with the possibility of similar effects in the US. More than the surfacing of different spatial-timings, I also show how care technology itself can shift and transform, namely from a disciplining device to one that flexibly and more implicitly coordinates collective decisions about care and how it should move. This insight echoes the notion of care as a human-nonhuman collective, which accompanies my zigzagging ethnographic passages. Thus, comparative tinkering has produced a heterogeneous comparator akin to Deville et al.’s formulation of a heterogeneous ‘comparator assemblage’. Next, to further articulate the potentials of comparative tinkering, I turn to the issue of clutter in care and how it can generate additional opportunities to compare.
Comparative Tinkering with Clutter
In ‘Clutter Moves in Old Age Homecare’ (Lutz 2010), I consider the relation between domestic clutter and how it moves in US senior home care. This article starts with the observation that many US seniors live with household clutter. The gerontological literature often classifies this clutter as a hazard that can lead to problems with mobility, especially falling. However, I found that some US seniors used clutter in ways that challenge the conception of risky clutter. In my article, I unpack the category of clutter and highlight its positive implications for US senior home care. This includes rethinking the category of clutter as ‘care technology’. For instance, some of my informants created cluttered ‘nests’ around their favourite chair or bed to reduce the need for physical movement around the house. These cluttered nesting relations could comprise many things – from reading materials to personal healthcare items such as pillboxes, eyeglasses, mobile phones, and remote controls. Other more ‘sentimental’ collections suggest another type of clutter care technology, which mix with concerns about ageing identity. Examples here include love letters, family photographs, and favourite antique heirlooms. A few US seniors also had relatively elaborate systems of organisation. For instance, I relate how one informant kept a series of shoeboxes for each of his children. Every time he found an item concerning one of his children, he put it in the corresponding box for later distribution. Based on such findings, my article proposes the notion of ‘clutter technology’ to think through the productive and beneficial aspects of clutter in US senior home care. As such, the article tinkers with the category of care technology.
Household clutter was present in some of the Swedish situations I encountered, and I also found examples of nesting and distribution. Hence, this comparison suggests that clutter moves with care in similar ways, in both countries. However, I found clutter more often and in greater quantities in my US fieldwork. For instance, in some US homes, papers, clothing, food, and other objects littered the floor to such an extent that I could not easily walk in a clear path. Given this stark contrast between the US and Sweden, a transnational comparison of clutter seemed lopsided, uninteresting, and not worth noting.13 Nevertheless, as with the previous article, I had the sense that I had missed a comparative opportunity.
Next, I revisit a different set of ethnographic passages to tinker with the potentials of this transnational comparison, unpacking further the notion of clutter as a kind of ‘technology’ for care. In my Swedish fieldwork, I met Anna-Lisa, eighty-one years old. She had arthritic pain that made walking difficult. Her doctor had prescribed medication, but the side effects made her feel tired and weak. Eventually she decided to take her care into her own hands. Despite her pain, she stopped taking several of her medications, improved her diet, and increased her exercise. When she started feeling better, and grew weary of the public home care visits, she discontinued this service too, including help with cleaning and physical therapy.
Anna-Lisa lived with some domestic clutter. Compared with the US, however, it was not extreme. Even more remarkable was her cluttered assortment of pets. Anna-Lisa had grown up on a farm. Upon retirement, she decided that she wanted the experience of living with animals again. When I met her, she had six cats, two dogs, a parakeet, and several pet mice. This, I proffer, introduces a different form of nonhuman clutter – what Haraway (2008) might call ‘multispecied’ clutter.
The care for these animals presented some practical challenges, especially with her painful arthritis. For instance, she was unable to walk the dogs or clean the litter boxes as frequently as needed. Apparently, a neighbour had caught wind of her difficulties. One day, based on an anonymous tip, the Länsstyrelsens Djurskyddsinspektion (Swedish Animal Protection Authorities) paid her an unannounced visit. They found her home too cluttered and unhealthy for the animals. A few weeks later, she received a letter that proclaimed her unfit to care for the animals and banned her from keeping them. The authorities also billed her for their legal process. Upset and angry, she appealed the decision. However, she lost and the authorities forced her to give the animals away. After this, she struggled with a bout of depression. She explained that she perceived her pets as part of her well-being and self-care and that they had helped keep her active:
The animals gave me life. They cared for me in their own way. They gave me the company I needed and physical attention. Now, without them, I get filled up with silence and loneliness. So I have that instead. I am filled up with the loneliness and try to find ways to empty some of it out but it’s not easy.
This ethnographic passage highlights how different categories of care and clutter can generate comparative frictions in practice. A key example here is the way the Swedish authorities attended to pet care, but ignored the importance that multispecied clutter played for Anna-Lisa. Here, the comparison of an actual care situation to an inflexible standard of ‘pet care’ produced an unfortunate outcome – namely a senior who lost her care companions. This also suggests how a standardised comparison can deny the opportunity to tinker with a mutually beneficial arrangement.14 In other words, although the categories of senior home care or domestic clutter do not typically include animals, here the categorical shift is clear. More importantly, this tinkered comparison suggests an ethnographic passage back to my US material.
In the US, I worked with Beth, who was in her in her mid-nineties, and her granddaughter, Mary, in her mid-fifties. Mary’s mother had died fifteen years earlier. On her deathbed, Mary had promised her mother that she would take care of Beth. For the past fifteen years, Mary drove once a week to visit her grandmother, a two-hour round trip, to the house she had lived in for more than sixty-five years. Until recently, Mary had enjoyed these visits. She had taken Beth out for lunch, or just sat and talked. Gradually, though, Beth’s health declined. Her ailments included glaucoma and blindness in the right eye, severe osteoporosis, acute neck pain, congestive heart failure, hearing loss, and difficulties linked with mobility – for example, walking, balancing, and climbing the stairs. Mary had started to notice more bruises on Beth’s body, but Beth denied falling and insisted that her guardian angel had caught her. Mary joked that he must have been missing her more these days. Mary also suspected that Beth had developed Alzheimer’s disease because Beth increasingly mistook Mary for her mother, and found it difficult to recall recent conversations.
With Beth’s decline, her home became cluttered and disarrayed. Mary added housework to her weekly visits. This included cleaning up and caring for Beth’s nine feral cats that she had adopted from the neighbourhood. Cat hair was everywhere. Their litter boxes went unchanged and their food bowls were often left empty. Like the architectural space itself, the house was seeped in their stench. The cats and their material relations had become synonymous with Beth’s home. In fact, her sentiments of home were so strong that Beth claimed she would die if she had to move away and leave her cats. Mary, on the other hand, felt she could no longer care for Beth or her cats without extra help. Mary had raised the topic of paid home care, but Beth quickly dismissed the idea, exclaiming, ‘I don’t want a stranger in my house!’
Mary discussed the possibility of assisted living with Uncle John, Beth’s only remaining son and legal guardian, but he refused. He was determined to respect his mother’s wishes. Mary felt, however, that he did not understand the situation. John lived several hours away and was extremely allergic to cats, so when he did visit he did not stay long. Mary also reasoned that John was in denial about his mother’s decline. He avoided discussing her condition and what to do about it in conversation. Mary felt stuck. Then, one day, John showed up to take Beth to her dentist appointment. When he arrived, he found his mother on the floor, unable to get up. Apparently, she had tripped over one of her cats. Mary partly joked that this had joggled John’s perspective: ‘It was the straw that broke the cat’s back’. John had finally realised that Beth needed constant care and it should be him. For nearly a month, he gave Beth regular meals and saw that she took her medications. Yet, due to his cat allergies he could not stay in the house for more than a few minutes at a time. Instead, he lived in his camper truck parked in Beth’s driveway. He quickly grew tired of this arrangement, however. He finally agreed to take Beth for a medical check-up, which confirmed her poor condition. John finally accepted that Beth now needed more intensive home care.
In the meantime, it was difficult to find someone Beth liked enough, and who was also willing to put up with her cats. For instance, one woman had all the necessary qualifications, but during the interview Beth protested that the she had hit one of the cats. The woman explained that she had only reached out to pet it. Mary explained that it was unlikely the applicant had hit the cat, and attributed Beth’s reaction to her Alzheimer’s and increasing anxiety. Another applicant, Charlene, had shown extra affection for the cats, and Beth took an immediate liking to her. Charlene explained later that she sensed that the cats were the key to Beth’s trust. ‘Beth’s cats are her everything, and you must respect that. She watches the cats to see how they react and she observes that they trust me’. Beth added, ‘You spoil them like I do. You really do care’. Mary later confirmed, ‘Charlene earned Grandma’s trust by taking care of her cats […] They’re still Grandma’s cats, but now there’s somebody else who cares for them too’.
Like Anna-Lisa’s care, Beth’s cluttered assemblage of humans and felines emerges as a kind of care technology, with specific effects. This human-nonhuman care collective played a decisive role in the tinkering of comparisons in Beth’s home care – especially decisions about present and future care arrangements. Beth’s cats mattered in her ability to care for herself and her home. They also impacted how others adjusted and tinkered care with her. This included discussions with the doctor and the hiring of additional home care work.
Here, then, as with the example of spatial-timings in care, an opportunity for transnational comparison emerges. Where a comparison once seemed undeserving, now the notion of multispecied clutter as care technology offers a way to move comparatively between two different entities, namely senior home care in the US and Sweden. Rather than using standardised scientific categories which stem from etic or scientific terminologies alone, my comparisons tinker with care relations as they move in ethnographic passages. Admittedly, I am implicated in this work. It also requires analytical care to tinker these ethnographic passages together into a suitable comparator. As a social scientist, I have an interpretive hand in directing the results. However, it is not my ambition to expose these comparisons to further analysis at this juncture, as doing so would exceed the scope of this chapter. Instead, my aim has been to outline the potentials of careful comparative tinkering and how it can unlock new avenues for social scientific comparison. It requires a retrospective and open disposition towards the multiple and empirical-conceptual relations as they come together in ethnographic passages.
[…] To mark or point out the similarities and differences of (two or more things); to bring or place together (actually or mentally) for the purpose of noting the similarities and differences. […] [Construction] with (or to) another; together. […] to vie with, rival.
– Oxford English Dictionary [OED], 2nd edition.
This definition echoes several points I have made in this chapter. First, it mentions the movement of bringing together two or more entities. Thus, to compare implies the gathering and assembling of different comparative elements, similar to Deville et al.’s proposal of a heterogeneous comparator. I have developed this as the gathering together of care moves in ethnographic passages. These entail the noting down of similarities and differences. Hence, to compare relates to the making of noteworthy observations and descriptions, travelled and written in ethnographic passages between field and desk. Moreover, comparative collections do not contain exclusively similar elements. Rather, they entail inherent frictions stemming from their relational combinations. This dimension is clearly present in the etymological roots of the Latin term comparare (com- ‘with’ + parare ‘prepare’), which the OED states as the bringing together to form pairs for a contest or match. This last aspect brings home the significance of comparative tinkering with care moves and their frictional relations, as in to vie with, or rival. Comparison is anything but smooth.
Regarding the implications for social science, my argument is that comparative tinkering offers a means to stay with the trouble of comparison. It focuses on comparisons that emerge with the movements of care in practice. From a conventional view, such frictions easily render comparison unworthy of pursuit. In this chapter, I develop comparative tinkering as a means to transform such frictions into productive potentials for knowledge, which ‘dance’ in retrospective zigzags with ethnographic passages. This is akin to Gad and Jensen’s proposal of ‘lateral comparisons’, which open up new comparative travels. It also resonates with Strathern and others who propose the comparison of others’ comparisons. These concern how care workers negotiate and compare their own care moves. In addition, there is an affinity here between comparative tinkering and Mohácsi and Morita’s notion of travelling comparisons.
Although my ethnographic passages do not evidence people’s comparisons with care in other countries, they do relate to how technology helps to trace the tinkering comparisons of others in their moves with care. Thus, I argue that tracing the use of technology in ethnographic passages can locate additional opportunities for social scientific comparison. I would also add the importance of remaining attentive to how transformative frictions in practice can ontologically shift the comparative categories themselves. For instance, in my examples I experiment with how care technology transforms with the tensions found in the scheduling and cluttering of home care.
The above ideas point to the analytical treatment of comparative tinkering as a transformative heterogeneous comparator which integrates ethnographic passages. This focus on ethnography resonates with another point Morita makes about the mutual entanglement of ethnography and technology as a comparative ‘machine’. For instance, he writes, ‘[w]e have here a sort of ethnography that works as an evocative machine and a sort of machine that evokes an ethnographic [comparative] effect’ (2013b: 16). This way of seeing the interrelations between description and analysis has inspired my use of ethnographic passages as a fundamental component of comparative tinkering. Such ideas echo other scholars who view the importance of ethnographic writing as a social scientific intervention (Michael 2012; Vikkelsø 2007; Winthereik and Verran 2012). Mike Michael, for one, proposes a move from the notion of written stories – or anecdotes – to ‘anecdotalization’ for interrogating the social scientific research process itself:
As a form of telling that gathers into itself previous tellings and performs critical reflections upon the mutualities of such tellings and retellings and the analytic resources that made such tellings tellable, anecdotalization has both a topological and a nomadic flavour. In terms of the topological, it brings together what might once have seemed distant and disconnected: past episodes that are marginal and trivial illuminate contemporary moments of critical reflection and reorientation, and contemporary concerns render what had long been uninteresting past moments full of relevance. This bringing together of the distant and disconnected is also a marker of the nomadic or the rhizomic, according to Deleuze and Guattari (1998). However, the nomadic serves to emphasise what is processual, iterative, emergent and, crucially, changeable and shifting in anecdotatization (2012: 33).
Michael’s anecdotalization thus situates a rhizomic and topological move, akin to the gathering and cutting of ethnographic passages, which crisscross in surprising and often dubious ways. Similarly, I have proposed that ethnographic passages situate avenues for a generative comparative methodology – one that not only records, but also brings together and tinkers with comparisons. Comparative tinkering with care moves in ethnographic passages thus suggests rough travel, reminiscent of Serres’ (1980) northwest passages that mediate and intervene as they entangle complex frictions.15 In a similar way, I have drawn on ethnographic passages that interweave the empirical with the conceptual – travel with text – in the same analytical and careful move.
This chapter opened with considerations about the relation between movement and social scientific comparison in anthropology and STS. Inspired by such work, I propose comparative tinkering as a generative approach for gathering together different care moves with ethnographic passages. To background my approach, I turn to how the gerontological literature typically treats the challenge of transnational comparison of senior care in Sweden and the US. Standardised categories linked with economic and medical terminologies emerge as important comparative features in this literature. However, I argue that such categories can also sidestep the more nitty-gritty moves on which senior home care depends. At the same time, the different ways care moves and transforms in practice are what make the transnational comparison of senior home care so challenging.
To explore my own efforts to compare, I revisit two previous publications that sidestep transnational comparison. In the ‘Surfacing Moves: Spatial-Timings of Senior Home Care’ (Lutz 2013) article, I trace ethnographic passages concerned with how different spatial-timings in Swedish senior home care move. These passages implicate technologies for scheduling care, and the way they mediate comparisons in the pursuit of sustainable care. When writing that article, I did not find an opportunity for a noteworthy comparison in my US material. In retrospect, however, I realise that I allowed the standard practice of formalised scheduling to cloud comparative opportunities, particularly the informal use of mundane care technologies in the US. By opening up the category of scheduling care technology as a more fluid category, I found additional ethnographic passages in which to tinker with my comparison. This move rested on how my informants comparatively tinker with the scheduling of senior home care in the US and Sweden to negotiate the multiple spatial-timings that surface in this practice. In other words, attention to the ways my informants comparatively tinkered with the scheduling of senior home care also partly inspired my own comparative tinkering in and with ethnographic passages.
In my second publication, ‘Clutter Moves in Old Age Homecare’ (Lutz 2010), I focus on clutter in US senior home care as a kind of care technology. Here too, transnational comparison initially appeared unworthy of pursuit. Although I found similarities in the ways seniors in Sweden and the US interacted with their household clutter, my hesitations stemmed from the degree of clutter I found in several of the US home care situations I had visited. In these situations, the extent of clutter was so extreme that it seemed incomparable to anything I found in Sweden. Nevertheless, by rethinking and re-tinkering with the ethnographic passages, which involved multispecied clutter, I could tinker with a different tertium comparationis to open up new insights about clutter as a form of care technology in both countries.
This chapter has sought additional avenues for the pursuit of comparison that go beyond the standard measures of national healthcare systems. My aim has not been to discount comparisons that employ standardised categories or statistical models, but to locate additional reflexive pathways for comparison. I have proposed the notion of comparative tinkering with care moves in ethnographic passages as a topographical and heterogeneous comparator. This resonates with Mol’s (2008, 2010) assertion about care on and in its own ‘terms’ – in other words, those which resonate both conceptually and empirically with how care moves in practice, along with their generative or frictional affects and effects. As such, I suggest that comparative tinkering with care moves offers another route to think through, and with care, in contrast to terms for care that stem from medical ethics or policy jargon.
As such, my proposal entails several interrelated implications for the careful transnational tinkering of social scientific comparison. For instance, one implication concerns the importance of ethnographic passages (and how they entangle text and travel) to establish a heterogeneous comparator. Another point concerns the tangled movements in care and how these can disturb or re-tinker with standardised categories of comparison. In turn, rather than stifle or throw out comparison, I have argued that ethnographic passages offer fodder for the comparative tinkering of care, including its standards and categories. This also raises a point about the careful adjustment of frictions between etic and emic comparisons found in practice.
In a complex world where misunderstandings seem increasingly prevalent, it is important to stress the potentials of comparative tinkering as a method for opening up additional transnational comparative perspectives, which also embrace nitty-gritty moves of specific practices. Senior home care has been both the source and testing ground for this notion. However, I also hope this chapter can inspire readers to pull the notion of comparative tinkering in ways that stay with the trouble of care – in all its forms – which concern humans as well as our worldly others.
I wish to acknowledge the following individuals and opportunities. Casper Bruun Jensen, Randi Markussen, Tine Tjørnhøj-Thomsen, and Antonia Walford gave me useful feedback on my early ideas about comparison. The ‘Comparative Relativism’ symposium at the IT University of Copenhagen in 2009, as well as the ‘Mega-Seminar’ on ethnographic comparison, organised by the Danish School of Anthropology and Ethnography in 2011, were influential occasions. Later, in 2011, I co-organised a round-table event with Heather Swanson on ‘Comparative Tinkering’ at the University of California, Santa Cruz (UCSC). I found much inspiration from the participants, who included Karen Barad, Alan Christy, James Clifford, Lawrence Cohen, Donna Haraway, Susan Harding, Andrew Matthews, Danilyn Rutherford, Warren Sack, and Anna Tsing. In my final stages of writing, Annika Capelán, Alice Santiago Faria, Tora Holmberg, and Zehorith Mitz gave me invaluable comments. The editors of this volume also helped me sharpen my argument. The European Commission’s Marie Curie Actions programme (grants 14360 and 249322) and the IT University of Copenhagen financially supported my research.
1 Steven Connor has translated Serres’ passages as ‘complex, digressive, irregular, unpredictable, encompassing wormholes and back-alleys as well as highways – between the different modes of knowledge’ (2009: 2).
2 The term ‘tinkering’ has earlier roots in scholarly usage. For instance, the French anthropologist Claude Lévi-Strauss (1966) introduced ‘bricolage’ (the French equivalent) as a form of sociocultural invention for making do in novel ways with the limited resources available. Tinkering also finds traction in debates about evolutionary transformation (Jacob 1977; 2001).
3 John Rowe is Professor of Health Policy and Management at Columbia University. He is also a former professor of medicine and a founding director of the division on Aging at Harvard Medical School.
4 Parker’s article, from 2001, references a population of 8.6 million in Sweden and 250 million in the US, which indicates a significant population growth in both countries.
5 These authors differentiate this further as ‘Instrumental Activities of Daily Living’ (IADLs) and ‘Physical Activities of Daily Living’ (PADLs).
6 Some authors use Sweden as the exemplar of a welfare state (Wang and Aspalter 2007).
7 Social Intelligence For Tele-Healthcare (SIFT) was a European Marie Curie Actions funded research project (2006–2008), hosted by Philips Research. Its interlinking interests between business, technology development, healthcare, and government, although highly influential, are beyond the focus of this chapter.
8 Some might argue that such practical concerns would not influence pure academic research – in other words, without industrial or applied constraints. Nevertheless, I would argue that any social scientific research project must cope with multiple constraints that demand ongoing negotiation and tinkering. Thus, I maintain that the notion of ‘pure’ research is misleading.
9 Recursively, I found evidence that these complex care moves situate multiple social dimensions such as class, ethnicity, education, and gender. However, I will not develop these aspects here.
10 For ethical reasons, I did not recruit people with dementia in either country.
11 In my follow-up research, smartphone-based digital schedules had replaced the paper schedule. Yet, the care workers continued to conceal these devices during hands-on care work in a similar way.
12 In my work I use pseudonyms for all informants to protect their identity.
13 However, such comparisons do exist. For a Danish example, see Skov (2012).
14 However, there is supporting evidence from Sweden and the US that pets can positively affect care for seniors (Banks and Banks 2002; Beck-Friis et al. 2007; Hejra 2009; Folkesson 2011; Höök and Höök 2010). For instance, one article (Folkesson 2011) mentions a Swedish study involving dog care at a nursing home for seniors with dementia. After six months, the dog’s presence had reduced worry and violent outbreaks as well as the need for medication. Other studies have compared live and robotic dogs for senior care (Banks et al. 2008), while Philips Research (2014) has developed the iCat for ambient intelligence research and robotic pet interaction. Such studies resonate with Anna-Lisa’s story, and suggest the relevance of comparing different notions of care and its technologies, including relations with ‘multispecied’ clutter.
15 Michael also draws on Serres’ philosophy to develop the concept of anecdotalization.
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