Already Toast: Caregiving and Burnout in America is writer Kate Washington's deeply honest, beautifully articulated story of her sudden transformation from an energetic, happily married, career-focused mother of two into a lonely, isolated and exhausted sole caregiver to a chronically ill husband and young children traumatized by their family's health crisis. Offering historical, classic literary and contemporary perspectives on caregiving within the broader context of feminism and U.S. politics, Already Toast is a courageous battle cry, a call for greater recognition of, and support for, the invisible army of caregivers nursing America's ill, disabled and elderly populations.

Washington begins in late summer 2014, before cancer wedged itself into her family and forcibly reconfigured its priorities. A gifted storyteller, she paints a charming portrait of life in Northern California with her husband, Brad, and their daughters, the youngest about to start elementary school. Brad was a tenured English literature professor at Sacramento State University, while Washington successfully juggled her parenting and home responsibilities with a prosperous freelance writing career. She was still fragile after her mother's suicide a few years earlier, but the future looked bright. Working toward a more equitable marriage was one of the couple's ongoing goals, a mission that was sidelined with Brad's diagnosis of blood cancer in 2015, a lymphoma so rare it did not have a name.

For the next two years, Washington set aside her cherished writing career to care for Brad full-time, not because she chose to do so, but because there were no other reasonable options available to her within the U.S. healthcare system, despite her family's excellent medical insurance benefits. After extended hospital stays for a ruptured tumor and near-fatal complications from a stem cell transplant, Brad was sent home despite requiring 24-hour care.With minimal, inadequate training and no support, Washington was compelled to perform skilled nursing tasks, such as administering life-saving intravenous antibiotics and nutrition to her husband, while also navigating a complex web of medical insurance claims and hospital bills. It became a challenge to care for him without losing herself. Self-care was at the very bottom of an overwhelming list of priorities, while exhaustion and depression became a natural part of her life.

The reality for Washington was that the extended period of caregiving stripped away more than just her career. It also erased her identity as a person with dreams and desires of her own and alienated her from friends. Unprepared for the ways in which caring for Brad would take a toll on her personhood, Washington is blunt in her assessment: "Even motherhood... hadn't erased me so thoroughly." The author's devastating honesty is complemented by her ability to see humor in situations where all-consuming despair would be an understandable response. Recounting the time when a mummified bat fell out of the attic and terrified her and the children, Washington cuts herself some slack: "I would love to be someone who can calmly dispose of a dead bat, but I wasn't a great feminist role model that night."

Under constant pressure to be sunny and upbeat, the author found herself performing the roles of "Good Caregiver, Good Mom or Good Woman" around the clock. Contrary to the feminist narratives of our times, she notes, women in the U.S. are assumed to be natural caregivers and expected by society to give up jobs, ambitions and their hard-earned autonomy to care for family members, performing unrecognized and unpaid labor that endangers their own health and wellbeing. She points out that a well-intentioned but inexperienced caregiver can be dangerous for patients; it's only a matter of time before burnout makes the caregiver even less capable of performing the crucial role of keeping their loved one alive. Washington is pitch perfect in her blunt assessment of the shortcomings in America's callously individualistic approach to health and long-term care and its glaring lack of a social safety net for chronically ill Americans and their caregivers. She offers comprehensive, realistic federal policy suggestions, citing examples of states that are heading in the right direction, as well as countries such as Japan, which has adopted a more humane, community-oriented approach to caregiving, and Belgium's generous leave policy providing up to 12 months of paid leave for caregivers.

Washington ingeniously weaves throughout Already Toast entertaining as well as comforting references to female caregiving characters in her favorite literature, books she knew intimately during her academic studies but rediscovered through a different lens during Brad's illness. Fans of Jane Eyre, Middlemarch, Little Women, Anne of Green Gables and the beloved children's book Madeline will enjoy Washington's engaging, spirited discussion of caregiver models prevalent in Victorian times and beyond.

Washington generously shares the caregiving resources she discovered on her steep learning curve, hoping to make the path easier for those who come after her. Ambitious in scope, Already Toast outlines a reasonable roadmap for the future of caregiving in America combined with engaging prose that captures the complexity of one woman's struggle to maintain her "wavering sanity" while experiencing severe burnout. --Shahina Piyarali

(photo: Judith Basya)

Essayist and food writer Kate Washington is a dining critic for the Sacramento Bee. Her work has appeared in many publications, including the Washington Post, Eater, Catapult and McSweeney's. Already Toast: Caregiving and Burnout in America (Beacon Press, $26.95; March 16, 2021), her first book, documents the years she spent providing full-time care to her cancer-stricken husband and offers pragmatic policy solutions to the U.S. caregiving crisis.

What made you decide to write Already Toast? Was it difficult to re-live your husband Brad's intense illness through your writing?

In a way, the decision to write Already Toast evolved rather than being a conscious choice--my writings about Brad's illness began while he was still ill, in part because I was keeping an online journal to keep friends and family members informed and in part because I was in an online writers' workshop where I shared occasional bits of more personal writing--sometimes rants!--about the challenges of the situation. Writing about it was an outlet for some of the more difficult emotions I was wrestling with, particularly through the hardest year of 2016. As I came to the end of that year, I realized I was starting to have a lot of material and that there was no book out there that said the things about caregiving that I wanted to say. I hoped to write the book I'd wanted to read while I was going through it, so I took up a challenge from my workshop leader to adapt NaNoWriMo [National Novel Writing Month, in which participants aim to write 50,000 words in the month of November] to my project, and aimed to have a full draft, of the memoir material at least. The book has taken on a very different form than that early work, and much of the revision involved adding research and context. It has been valuable--though, as you suggest, often painful--to be able to revisit that early, raw writing from when things were hardest. At the same time, often I've been reminded in writing and revising of how much easier our situation is now, and how far Brad has come, despite his ongoing chronic illness.

As you described so poignantly in Already Toast, a marriage can suffer irreparable harm when one spouse is chronically ill for an extended period and the other spouse is their full-time caregiver. What strategies have worked for you and Brad to rebuild your marriage now that he is in remission?

To be honest, it's been slow going, but we have had a lot of couples therapy as well as individual therapy. One of the challenges has been our different interests and energy levels; I'm always wanting to go places and do things, whether it's a hike or a household project, and Brad is much more content to take life slowly. In some ways the pandemic has forced me to slow down and given us some shared activities. It sounds small, but one thing we did as a family that brought us all a little closer was trivia nights: we all took turns writing trivia quizzes for the other family members. I also hurt my back at the beginning of 2020, which I don't recommend at all as a strategy, but which did have the side effect of giving Brad a bit of an opportunity to care for me. It's still a work in progress, but we're trying.

Is there a literary caregiving figure you relate to most closely?

This is a tough one! I would say that early on I identified most with the character of Leslie Moore from the Anne of Green Gables series (she appears in the fifth book, Anne's House of Dreams)--she was the subject of the first essay I published on the theme of caregiving, which appeared in Avidly. Her sense of being set apart by her situation as a caregiver really spoke to me, as did her resentment, to be honest, and her character's backstory includes the death by suicide of a parent, which I unfortunately identify with as well. I also find a lot to identify with in Middlemarch's Dorothea Brooke; the issues in my marriage are very different (and my husband, as I say in the book, is hardly a Casaubon!), but her difficulty in grappling with the compromises marriage entails while staying true to both her vows and herself is something I feel deeply whenever I reread Middlemarch, which I do every couple of years.

Which countries do you think have the best support system for caregivers, whether that is caring for young children, the elderly or those chronically ill or disabled?

I haven't had the experience of caring for others in any country other than the U.S., so it's hard for me to say with certainty! But I will say that I look with longing at the kinds of support measures that are in place for families and caregivers across most of the European Union, especially the more I hear about the strain on individuals providing care to others throughout the pandemic. From what I've read, Japan is also at the forefront of efforts to rethink eldercare in particular. To me, the key is that in the U.S., the broader culture seems to think of care, in all its forms, as an individual problem to be solved--often by a woman who's already strapped for time and resources--rather than a systemic problem to be addressed by broad societal solutions. I was recently reading the author Anne Helen Petersen's newsletter, where she interviewed a sociologist, Jessica Calarco, who gave the key quote: "Other countries have social safety nets. The U.S. has women." That has really stuck with me.

What are some of the federal policy changes with respect to caregivers that you hope to see implemented?

I often hear tax credits floated as a solution for caregivers, but personally I would much rather see relief in the form of direct aid and guaranteed paid leave for caregivers--not to mention paid sick leave and job guarantees for care recipients. Both the latter suggestions and universal health care sound like they would benefit sick individuals the most, but they have incredibly important implications for caregivers, as well. Really, though, the need for a robust social safety net is so extreme, and so interconnected, that any change would represent progress. I am hopeful that we are ready for a national reckoning with how we can better care for each other as a society. My greatest hope for Already Toast is that it can be a part of that bigger conversation. --Shahina Piyarali