When Short-Term Care Isn’t Enough

 Maturing survivors of domestic violence need a long-term life course approach to health care.

I first met Marisa at a domestic violence crisis center in Connecticut. A weathered 64-year-old immigrant from Colombia, she had been living in the United States for 28 years and had become a citizen. Marisa had tirelessly worked factory jobs to provide for her three children for decades and through two difficult marriages. Over time, her experiences had taken a toll on her body. Marisa grappled with several ailments, including a chronic respiratory disorder and clinical depression, all exacerbated by years of manual labor. Now grown, Marisa’s children lived out of state and did not take care of her as she had expected—she lived alone and on disability assistance. As I got to know Marisa, I learned more about her current relationship. Her “friend,” as she called him, provided much needed support: getting her a cell phone, helping around the apartment, and bringing her to the doctor. Yet, he was growing controlling and abusive. His presence in her life further isolated Marisa from her children, but she was afraid to be left on her own with her ailments and medications. She found comfort in the center and frequently participated in support groups and workshops. These services were intended for short-term crisis relief, yet Marisa had been attending for five years.

George Dowie/Flickr (CC BY-NC-SA 2.0)

Like Marisa, survivors of intimate partner violence (IPV) encounter various challenges as they age. While medical and social service providers have become more aware of the effects of abuse on bodies over time, there are still few safety nets for aging survivor care.

A public health crisis

Over the last several decades, advocates have championed more attention for IPV as a national public health crisis. The IPV field in the US has grown from a grassroots movement led by survivors helping other survivors into a federally funded, professionally driven services system. Advocates continue to work towards identifying structures that perpetuate violence in the hopes of breaking down institutional barriers and increasing recognition of and resources for IPV survivors in the health care sector.

As Marisa’s experience shows, IPV can disrupt social care networks and cause additional strain on the body. IPV may also make it more difficult for someone to access proper health care or take medication as directed. At the most extreme end of the spectrum of violence, IPV threatens life; intimate partners commit 38 percent of murders of women worldwide. Yet the prolonged, acute stress associated with such violence can also lead to complex neural, endocrine, and immune responses that significantly shorten the lifespan and limit quality of life. IPV leaves people more susceptible to chronic disorders, pain, and ailments such as cardiovascular disease. Abuse and its effects further manifest through mental illness, including depression, anxiety, and suicide, and sexual or maternal health outcomes, such as premature labor and sexually transmitted infections. IPV also leads to injuries that may permanently limit movement and well-being.

Many IPV shelters are also not equipped for disabilities, and aging survivors need different types of safety planning not always accounted for within current domestic violence service models.

For low-income immigrant survivors in particular, the compounding of these health consequences by unequal access to health care, grueling labor, and lack of education or language ability exacerbates this grim reality. During fieldwork at the center, I spent time with Marisa and immigrant survivors like her who had been utilizing these services for more years and far longer than the short-term crisis care they were designed to provide, finding little other accessible assistance. When survivors are abused by their partners well into middle and older age, it takes an additional toll on their physical resilience, finances, quality of life, and independence. As scholars of disability have argued, the difference between “debility” (the functional losses of the body) and “disability” are the ways that society fails to recognize and support this functional diversity. Although Marisa was a US citizen and recipient of government subsidized support, she had access to strikingly few safety nets—they simply did not exist.

The prospects for undocumented aging survivors are even more ominous, as they are not eligible for state assistance like Marisa, face additional layers of discrimination and violence, and have less access to medical treatment. Although all survivors require many types of material support, from housing to legal to transportation assistance, deteriorating health can lead to a more rapid decline in all other areas, especially as people age. As the elderly population in the US continues to grow, IPV will persist as a public health crisis.

A pre-existing condition?

Unfortunately, the strides towards greater recognition of IPV as a health issue have opened opportunities for exploitation. This past summer, public discord around calls for repealing the Affordable Care Act (ACA) highlighted the deep political divide over the government’s role in health care. While the ACA prohibited the practice of denying services based on a pre-existing condition, prior to this legislation, it was legal for insurance companies to deny health care or increase premiums based on a history of IPV. The 2015 NAIC Network Adequacy Model Act was created to curb this discriminatory practice, but not all states adopted the policy. Moreover, it has been difficult to track these practices, because insurance companies were never required to disclose this information. In current and ongoing attempts to instate a new health care plan, IPV advocates fear the resurgence of this insidious practice. Once again, IPV—or even more likely, its resulting health effects—could become grounds for prohibitively hiking premiums or even denying coverage for the one third of American women, and the men and LGBTQ individuals, who suffer this abuse at some point in their lifetime, not to mention immigrants with far more limited access to health care. On the one hand, labeling IPV a “pre-existing condition” is remarkably symbolic of how successful advocates have been at garnering recognition for intimate abuse as a health care issue. On the other, the consequences for maturing survivors are dire, particularly as they age and experience the long-term effects of violence on the body.

A long-term lens

While the lifelong health effects of IPV are now starting to be known, the limited capacity of domestic violence centers forces them to focus on the “short and mid-term,” as one crisis center director explained to me. Another social worker in Connecticut, whose job was to advocate for aging survivors of IPV, explained how such abuse must be better monitored across all health care facilities, from retirement homes to doctors’ offices. When frontline health care workers are properly trained, they are better able to detect abuse among aging people who cannot always advocate for themselves. Many IPV shelters are also not equipped for disabilities, and aging survivors need different types of safety planning not always accounted for within current domestic violence service models.

Anthropology can play an important role in advocating for these needs by highlighting the importance of a long-term, life course perspective. Through its unique capacity for “thick description,” ethnography can document the toll that cumulative violence takes on the body over time, and how those bodies face daily barriers to assistance and care. A greater understanding of the challenges faced by aging survivors of IPV is crucial to ensure safety and sufficient levels of care for people like Marisa. Ultimately, this focus is also necessary for the millions of Americans who depend on Medicare to support their quality of life into old age. Many Americans age with few societal supports or proper health care. Their experiences and needs demand our undivided attention.

Allison Bloom is a PhD candidate at Rutgers University. Her work in medical and cultural anthropology builds on fieldwork and professional experience in the social services field. She is currently investigating the disabling effects of multiple forms of violence layered over time for aging Latina domestic violence survivors in the United States.

Cite as: Bloom, Allison. 2018. “When Short-Term Care Isn’t Enough.” Anthropology News website, January 26, 2018. DOI: 10.1111/AN.751

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