"This is going to make me ill"

Some readers fear the opposite of penance, which is that the care itself will break them, and that fear is also fuel for guilt, because wanting to protect your own health feels like putting yourself before them. So let me be straight about what the research says, because it's more complicated and more hopeful than the folklore.

The folklore comes from one study. Richard Schulz and Scott Beach followed 392 older spouse carers and 427 non-carers for four years in the 1990s and found that carers who reported strain had a mortality risk 63 percent higher than the non-carers, though the margin of error on that figure was wide. That finding went everywhere. What went less far was the rest of the same paper. Carers who were providing the same care without reporting strain had no raised mortality at all. It was never caring that killed. It was strain.

Since then the picture has filled in. David Roth, Lisa Fredman and William Haley reviewed the population studies in 2015 and reported that five of them had found reduced mortality and longer life for carers as a group compared with non-carers, that most carers report benefits, and that many report little or no strain. Roth's own study matched 3,503 American carers with 3,503 similar non-carers and followed them for six years. The carers died at a lower rate, 18 percent lower, and no subgroup, not even those reporting strain, showed a raised rate against their matched controls. A separate analysis of the same cohort by Martinique Perkins and colleagues found that carers reporting high strain did die at a higher rate than carers reporting none.

Hold both. Martin Pinquart and Silvia Sörensen's meta-analysis of 84 studies in 2003 found carers more depressed and stressed than non-carers, with only a small difference in physical health, and larger differences for dementia carers. So caring is hard, and strained carers do worse, and carers as a whole don't die sooner and may live longer. The variable is strain, not hours. And the earlier chapters say where the strain comes from, which is obligation, guilt, lack of choice. The fear that caring will make you ill is best read as a fear that penance will, and there I think it's right.