The good news is that more people live longer than ever before. The oldest-old are the fastest growing segment of the older population. And herein lies the less good news: the longer one lives, the more likely one is to experience physical impairments. In 1989, 58% of those age 85 and older had some difficulty with activities of daily living; 87% of them actually received help. Most of these elders live in the community, supported by unpaid family care.

Life expectancies, disability trends and caregiving patterns vary by gender, race and social class. Until recently, much of the gerontological literature devoted to disentangling the effects of these "independent variables" was based on large-scale quantitative racial comparisons that ignored intra-group variations. The result was a largely stereotypical depiction of the African American family as more nurturing, more willing to bear the burden of caregiving, and more reluctant to seek formal care than their white counterpart. The myth of African Americans' avoidance of nursing homes has persisted despite growing evidence that African American families are as heterogeneous in their ability to provide care as are other racial groups. African American working and middle class families face the same challenges as do white families. All are subject to the same demographic and economic realities which set limits to kin care, and eventually make nursing home placement an appropriate and acceptable option when the need for care exceeds the ability of families to provide adequate care at home.

Our examination of state-wide data reveals that in Ohio African American elders are actually more likely than whites to use nursing homes.

I was Principal Investigator of a study that explored African Americans' ideas about filial obligations and their preferences and choices for long-term care. We conducted 8 focus groups with different age groups, and collected ethnographic interviews from 60 care recipients and caregivers, in three care settings (kin care, in-home-services and nursing home care) about their experiences receiving and providing care. Elders varied greatly in their availability of informal support, which ranged from unwavering and total support from many children, or no support whatsoever, to exploitation by their own children. The following story echoes the struggle of many of our participants to avoid or postpone nursing home placement, and their acceptance of it as a last resort.

Sylvia, age 50, has worked for the IRS for 29 years and expects to retire in 5 years. She intends to go back to school, cashing in on a deal she made with her son who agreed that he would help her finish college because she helped him become an electrical engineer. In the meantime, Sylvia has a second full-time job which is much more taxing than her work for the IRS: she takes care of her 79-year old mother who suffers from Alzheimer's disease. Sylvia checks on her mother by phone several times during the day; runs by in the evening to do chores for her; takes her to stores, medical visits and visits with friends. To do all this, Sylvia gave up two part-time jobs she had taken to save money for a down-payment on a house.

Sylvia has taken care of her mother for three years. She has visited a number of nursing homes, interviewed staff and chosen two facilities where her mother is on a waiting list. She feels that a nursing home would be the only place her mother would be completely safe. But her mother refuses to sign the papers. Sylvia is torn about the decision: she has already turned down one opportunity, and she thinks that when the next bed becomes available, she may well turn it down again because she believes one should take care of one's elders. In the meantime she lives the nightmare of imagining what might happen to her mother.

Cultural preferences notwithstanding, nursing home residents in our study had reached "that place" where their needs exceeded the capacity of kin care or in-home services. Their realistic choices had narrowed to a point that preferences had become irrelevant or inoperable. Although nursing home residents as a group were older, more impaired and had thinner informal support than elders in the other two settings, and in that sense resembled each other, they differed in their reasons and pathways for reaching "that place" and in their reaction to living in a nursing home. Initially, most residents disliked being in the nursing home, but they eventually accepted and adapted to institutional living. For some residents and their families, the nursing home became a "partner in caring" and allowed family members to step up their efforts to provide care. After prolonged and escalating struggles to provide kin care, timely and appropriate institutionalization restored care givers' peace of mind. It improved elders' sense of security, competence and well-being; and for some, it was a refuge from unsatisfactory kin care.

Through ethnographic interviews we discovered processes not captured by surveys that are the mainstay of gerontological research: family struggle with and adaptation to the declining health of elders; their unrelenting care-giving efforts; their ultimate failure to continue as primary care givers; their feelings of guilt about having failed in their filial obligation; and their acceptance of institutionalization as a last resort. The assumption that African Americans reject nursing homes is inaccurate and counterproductive to working and middle class families' search for appropriate care settings for elders whose care needs could best be met in a nursing home. African American families need not be reminded of their filial obligations; they need not be told that, as a group, they appear to reject nursing homes. What they need is assistance with exploring all possible options, guidance in anticipating scenarios that are likely to lead to nursing home placement, help with planning for increasing care needs and referral to such programs.