Families on the Edge

Overcoming untenable choices on work, health, childcare, and education

Humberto started to pace back and forth across the floor of the cinder-block home, cradling his son in his arms. There had to be a story. In this slum, no one had enough money to stay home voluntarily, and for most men, there was an awkwardness when they held an infant—infant care remained gendered work. Humberto had clearly been caring for his son for months.

He started in the middle of the story. Humbertocito—little Humberto—had been named after him. The boy was stricken by pneumonia as an infant. (Two million children under the age of 5 in developing countries died from acute respiratory infection in 2000.) When Humberto and his wife, Julia, took their only child to the hospital, they could not leave him, as parents might in a hospital in New York or Geneva, and expect that his needs would be met by nurses and attendants as well as physicians. Like poorly funded hospitals in much of the developing world, the public hospital where they sought care relied on parents to make sure their children ate, received medicine, had diapers changed. The hospital simply did not have the staff to do otherwise.

That meant Humberto and Julia had little choice but to miss days of work at their factory jobs to care for their son. The first day Humberto was absent, his supervisor told him he had to return the next day. The second day Humberto missed work, his supervisor told him not to bother to return. The third day Humberto missed work, he was fired.

When Humbertocito recovered from pneumonia, his father walked from one factory to the next looking for work, but it rapidly became clear he'd been blacklisted. At every door where he knocked, he was told there were no jobs—but frequently people who applied after him were hired.

This story of the connections among labor conditions, children's health, and family welfare in fact began earlier. Julia had needed to return to her factory job 42 days after Humbertocito's birth or she would have been fired. With long work hours and no way to breastfeed or pump milk during the day, the milk in her breasts dried up. The basic biology of breastfeeding provides essential immunity to infants, helping to fight off infections that are dangerous in the first year of life. Breastfeeding plays a particularly critical role for poor families in developing countries. Without breast milk, infants in these families too often end up severely malnourished because of the inaccessibly high cost of infant formula and the unavailability of clean drinking water. Fed too little powdered formula mixed with water filled with pathogens and pollutants, not protected by the immunoglobulins in breast milk, infants become much more vulnerable to gastrointestinal and respiratory illnesses. When Julia had no choice but to return to work too soon, Humbercito came down first with diarrhea, then with pneumonia.


The problems that low-income families confront stem as much from the lack of essential services for their children as from the poor working conditions parents face. In the same city where Humberto lived, I visited a shelter for families displaced by a hurricane and mudslides. As we walked back toward the barracks housing families who were still homeless two years after the disaster, we saw a small boy, his black jeans several sizes too big at the waist and too long, leaning against a metal pole as he stood watching people washing clothes in the communal sinks. At our request, 10-year-old Ramon led us the 30 yards from where he stood to the one-room shelter shared by nine members of his family. When he got to the open door, three of his younger sisters swarmed around him, delighted to see him back. His parents couldn't afford childcare while they worked to earn enough money, they hoped, to build a new home. Ramon was responsible for Martita, who was five years old, Cari, four, and Justina, three.

Ramon also cared for his two youngest siblings. When he pointed to Laurita, who he said was more than one and less than two, I couldn't tell where she was. There appeared only to be a doll sitting in a chair in the dark room, not a toddler. The body was completely immobile. Laurita's legs were thin as twigs, bent like those of children with rickets from malnutrition. Ramon explained that she never used her legs. He didn't know how to get her out of the chair or to encourage her to walk. Farther inside the dark room, on a bed, lay Beni, Ramon's five-month-old brother. Beni was on his way to being equally malnourished. There was a bottle at home, but Ramon didn't know how to prepare it; only his 14-year-old brother Miguel did. Even though all the children depended on Miguel to come home for them to have a meal, he was nowhere to be found.

Beni had a deep, penetrating cough. A bottle of medicine for his bronchospasm sat on a shelf in the tidy room. The label stated clearly that Beni should receive the medicine three times a day, but there was no one to administer it during the 12 hours that his parents were at work. Concerned that an overdose might be deadly, Ramon's parents had instructed him never to give the medicine to Beni.

Ramon was tender with his siblings and as attentive as one could expect a 10-year-old to be. But no 10-year-old could care well for five children five years old and under. Ramon was about to start third grade. He had repeated second grade because he had lost time when his parents asked him to care for his sister Justina, who had had convulsions as a result of high fevers. Her teeth were rotted from bottle-mouth, a result of being left unsupervised for hours on end with a sweetened bottle in her mouth.

Ramon's mother worked from six in the morning to six at night, six days a week. His father worked equally long hours. They clearly cared deeply about their children. But it was equally clear that because they needed to work long hours to meet basic needs, because they lacked childcare and had to leave their preschool children in the care of their 10-year-old, the health, basic development, and education of their children were all endangered.


I interviewed Humberto and Ramon as part of the Project on Global Working Families (PGWF), which I founded and lead— the first program devoted to understanding and improving the relationship between working conditions and family health and well-being throughout the world. As part of this effort, we have conducted four types of studies to date. First, we have mapped 40 years of demographic trends related to labor and families in more than 100 countries. Second, we have conducted in-depth interviews of nearly 1,000 parents in six countries around the world: Botswana, Mexico, Vietnam, Russia, Honduras, and the United States. Third, we have conducted statistical analyses on large national household surveys from Botswana, Brazil, Russia, Mexico, South Africa, Vietnam, and the United States. Combined, these national household studies surveyed more than 50,000 families. Finally, we are currently examining public policies from more than 100 countries regarding the conditions working-poor families endure.

The conclusions are clear. Millions of children are currently placed at risk by the devastating working and social conditions their parents face. These unconscionable conditions are in no way inevitable. Rather they are a product, at times, of deliberate exploitation, but far more often of malignant global neglect.


In every country where we have conducted in-depth studies, children are being left home alone. Twenty-one percent of the parents we have interviewed in Vietnam have had to leave their children home alone some or all of the time they worked, as have 37 percent in Mexico and 50 percent in Botswana. The experiences of preschool and young school-age children left home alone are often tragic. At 34 years old, Freedom Modise was caring for both her children and her elderly mother. She was paid for her labor on construction sites when she came to work, but had no leave benefits. Barely able to support three generations on her income, she could not afford the eyeglasses her daughter needed for school, let alone hire someone to care for her elementary-school daughters after school, so she left them home alone. Modise explained,

I found out about [my young daughter's rape] when I came back from work and saw that she was in one of our one-roomed houses in the yard, crying.... A man who sometimes helps us repair things in the house came by when Tebogo was home after school. He came into the yard and then forced himself onto Tebogo. She is now afraid to be home alone.

Too often, parents' only alternative to leaving very young children home alone is to leave them in the care of other children. In Botswana, 34 percent of the parents we interviewed have left their children in the care of other children, as have 24 percent of the parents in Mexico and 22 percent of the parents in Vietnam. Crista Robles worked as a domestic servant.

My son, who is two, had just left with his older sister, the one who is six years old....She didn't go [to school] today, because I told her to stay home. Because if she didn't, where would I leave my son?...Sometimes they tell me, "Mamita, don't work anymore, because we don't want to be alone." And I tell them, "But if I don't work, we won't be able to afford food."

When children are left home alone or in the care of other young children, they are far more likely to be inadequately fed, become malnourished, or be exposed to poor drinking water. At two years old or six, the children are simply too young to care for themselves or for each other. They don't know how to ensure that an infant eats enough. In countries where cooking requires fire, young children can rarely cook safely. Where clean running water does not exist in the household, obtaining it often requires traveling lengthy distances or boiling water. The consequences of using the more readily available unclean water are diarrhea and frequent infections. Accidents and injuries arise from young children being hit by cars when they are too young to reliably take precautions on the road, when they fall from heights when they are unsupervised, and when fires start when they try to cook. In Mexico, 48 percent of the parents we interviewed have had children experience accidents or emergencies while the parents were at work, as have 38 percent in Vietnam and 52 percent in Botswana.

Nunuko Ndebele was raising her seven children on the meager earnings she made as a cleaner. Unable to afford childcare, she often had to leave her children without any adult supervision. One day when her children were home alone, they tried to cook.

They were cooking while I was at work, using the gas stove. I think they switched one button on but didn't light the stove. I can't say what happened, but whatever they did, the whole house was in flames. Everything was burned out. We didn't take a single item out of the house, and when I got back from work, I found what used to be a house was now in ashes.

Nunuko was lucky that her children survived. Too often, families told us of tragedies involving fires which resulted in severe injuries and deaths when children tried to cook. As it was, Nunuko's family was left homeless and bereft of all clothes and basic necessities.

When the parents we interviewed stayed home temporarily to care for their own children, all too often they lost pay or jobs that were essential to feeding families. The simple act of caring for sick children led to lost pay, lost promotions, or difficulty retaining jobs for 28 percent of parents we spoke with in Botswana, 51 percent of parents in Mexico, and 63 percent in Vietnam. Pham Dieu Hien had been working as a factory seamstress when her son was born. He had suffered both acute and chronic medical problems, including epilepsy, since birth. She needed to miss work intermittently to care for him.

Each time when I took time off—I was working for a Taiwanese athletic shoes manufacturer—the schedule was very demanding. If I took one day off, then three days of salary would be taken off.

That cost was more than her family could afford.


The future of humankind depends on the ability of families to raise healthy children. We need to act rapidly as a global community to provide the social conditions that make it feasible for working parents to raise healthy children, and to ensure a floor of decent working conditions. Investing more in human capital—quality childcare programs, early childhood education, after-school and year-round programs that will give school-age children the kind of education that allows them to truly compete in the global market—is long overdue. For too long, global investments in resource-poor countries have focused overwhelmingly on physical capital. The World Bank, the International Monetary Fund, and other institutions have provided loans for dams, bridges, and roads. Yet the dollars loaned for these physical investments, while sometimes well-used, have too often been wasted ( if not stolen), and have come at the cost of human and social investment, leaving populations paying debts from which they have benefited little. Investments in human capital would mean that toddlers would not be left home alone and young children would not be pulled out of school to care for their younger brothers and sisters. These investments would increase the ability of resource-poor countries to compete for skilled-labor jobs in the global economy. Once reaped, no one can take these benefits away.

It is equally important that we fight for decent working conditions for all people. Adequate working conditions that allow parents to raise healthy and educated children should not be negotiable. The basic rights of those who work have been agreed to by 171 countries in the Universal Declaration of Human Rights—as well as delineated in scores of conventions developed by the International Labor Organization (ILO). What is lacking now is not theoretical consensus but practical commitment.

The negative outcomes of the poor working conditions we have documented are no more inevitable than child labor—an issue that attracted little public awareness, and even less political attention, two decades ago. While child labor remains a problem in 2003, the combined action of popular movements, a wide range of global and national nongovernmental organizations, individual initiatives, local and national governments, and international bodies—like the ILO, the World Bank, and UNICEF—has changed world views on the inevitability of child labor, and in particular reduced the number of children suffering in bonded labor. We need an equally strong global effort to address the devastating conditions that children in working-poor families around the world face daily. As a global community, when we begin to judge as intolerable—instead of as inevitable—parents earning too little to feed their families if they provide care for their children, parents losing jobs or being fined for staying home to care for a sick child, or missing work to care for a child in the hospital, the prevalence of such untenable conditions will decline as well.

Making this happen will take professional efforts by those working in large global intergovernmental organizations, national governments, local and international nonprofit organizations, and local and global companies. But beyond our professional roles, we will all need to be ready to pay for living wages and decent conditions not just for the people we can see in our neighborhoods, but also for parents in Honduras, Botswana, Vietnam, Mexico, and every other country. The world can afford to ensure adequate working conditions and social supports for families; what we can't afford is neglect.


Jody Heymann, M.D. '89, M.P.P. '89, Ph.D. '92, is associate professor of society, human development, and health at the Harvard School of Public Health. She founded and directs the Project on Global Working Families (www.hsph.harvard.edu/globalworkingfamilies) and chairs the Work, Family, and Democracy Initiative. She is the author of The Widening Gap: Why American Working Families Are in Jeopardy and What Can be Done about It (Basic Books, 2002) and Global Inequalities at Work: Work's Impact on the Health of Individuals, Families, and Societies (Oxford University Press, 2003), among other books and articles.        

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