Are We Failing Our Elderly?

What drew you to the work of geriatric mental health and geriatric care? 

A mentor at TISS inducted me into teaching a course called geriatric social work. That’s how I got involved in the field of aging. The starting point was being a caregiver for my dad 12 years ago. I was deeply shocked by the paucity of support mechanisms, despite belonging to a social class.

I had the knowledge, the literacy, the resources, but even then, I struggled so much. That’s when I realised that there is so much to be done. My interest deepened because often, literature showcases the elderly as a homogeneous group, either dependent or frail or with a disability. 

The narrative is always “dependent, sulky and slow”, and that’s the reason I thought a fresh wave of information is needed. We have to look at positive aging and also what support mechanisms the country offers to facilitate active or proactive aging. While the literature is communicating something different, the realities are diverse.

What are the alternate voices? Even in old age, how many of them are highly independent, contributing and productive, while their narratives are not so visible? What can be learned from those octogenarians who are active? This is how my journey first began; it was subjective experiences, looking at my own privilege and struggle. 

What are the support mechanisms that the state or the country can offer? 
In terms of policies, the government looks at starting old age homes and shelters or they talk about financial security. They talk about railway concessions, air travel concessions, senior citizens’ health insurance.

These are aspects the government offers. But there is clearly a paucity and a huge gap in terms of what the older adults need.

First, we are not an age-friendly country. When a city is truly age-friendly, you have mobility. The elderly can wheel in and out in public transportation.

They can cross the road, access places they want to go to. Thanks to the UNCRPD (United Nations Convention of Rights of Persons with Disabilities), now we have ramps and lifts, so senior citizens are also navigating certain spaces. Disability rights people are looking at how we can make the environment disability friendly, so older adults are also getting advantage of that.  

In other countries, there are clubs for senior citizens where members can go and play. In India, we don’t have these facilities or they are restricted to the elite or gated communities, where we have a laughing or yoga club for senior citizens.

How can we be more inclusive?  

We have to promote access to persons with disability. We have to define that disability is not the individual’s problem, it’s the society and the society mechanisms that make a person disabled and that’s why we always talk about how to make everything disability friendly.  

I noticed that sometimes we use disability and old age almost synonymously. There are two types of old age—there’s young old age—when you’re able to do most of the things that you could do—and there’s ‘old’ old age where you can do fewer things.

Then there is a stage where your bodily functions are limited, or you have some sort of illness or terminal condition, which makes you debilitated. But generally, everyone is bracketed as one large, amorphous sort of mass. 

When people stop becoming productive in a financial or a capitalistic way, how does it spiral with respect to mental health? 

In a way, asking people to retire at a particular age is ageism. They are asked to go, even when there is calibre. People talk about longevity, but in certain states, retirement is at 58. So, what do they do after 58? However, some shifts and transitions are happening.

People try to take up consultancy and they get back into the job market. Your value diminishes once you retire—if you are drawing one lakh per month, after retirement, they will ask you to work for Rs 30,000? If retired people ask for remuneration based on their capabilities, they are perceived as greedy.

This is one group—the recently retired, but there are also other informal spaces where older women are working. For example, they work as farmers. But people start viewing them as a liability because they can work for only two hours, and the resources are shared.

The urban market, the daily wage market or the gig market is huge, but senior citizens are not even considered for recruitment because “superfast” is the expectation of the Swiggys and Zomatos. Either they are automatically excluded or are seen as a liability. They’re not seen as profitable. 

Are existing health issues compounded by this isolation and exclusion? How can the system help?

It can be seen both ways. One is a loss of income or diminishing income, and declining health, and therefore increasing health costs. It’s like a social causation trajectory; you definitely feel vulnerable, and at the same time, you do not have support structures.

The concept of family as a support structure is also shattering. So, if you are unwell, you have to rely on trained support, which is hard to find and comes at a very high cost. 

If someone is ill and has no one who can look after adds to the stress factor. This is becoming a reality as families are also in transition. Most of the members are migrating within or out of the country.

The state also conveniently doesn't look at how families can be supported. There is no concept of parental care leave or compassionate care leave, like child care leave, which is usually a mother’s right. There is no legal provision for taking care of a parent—you have to go on leave without pay, there is no other option.

Monetary compensation is one factor, but some respite in the form of compassionate care leave must be provided, like some countries do. It’s not only the parents who are going through insecurities; the children who provide care suffer as well. They sometimes struggle to cope at their workplaces.

Isn’t care also about the patriarchy largely? 

True. In our country, care is often offered by women. Largely, 
it’s feminisation of caring all the time. It may be an older wife taking care of the husband or it’s daughter-in-law caring for in-laws and the parents, or it is the daughter. Inevitably, it is a woman. This is becoming a personal struggle, and is often documented as a personal struggle.

In its articulation, it will be about intergenerational conflicts, vulnerability and children not taking care of their parents; even the larger media portrays it like that. But when the family is ready to care, what are the provisions? Am I getting any parental caregiving leave?

If yes, then I will happily be a caregiver, but now, it’s an obligation. People often have to request their colleagues to pitch in or make an exception. Sometimes, people also ask insensitive questions—but you are three children; why can't you divide care? Families are structured in a particular way, so the caregiving is usually entrusted to one person or one child.

How can we be prepared for this inevitability? Are there any conversations we can initiate? 

If you look at the country data, we now have more number of people living alone than before. We often see in the news that a person is found dead inside their home after a week.

Also, unlike other cultures, we do not talk about loss, grief and bereavement; we never talk about death-related anxiety. Hospitals, a space that everyone commonly accesses, are also ill-equipped to address this.

They talk about diabetes, BP, but they do not talk about mortality or the feelings that arise from it—how do they feel? Are they feeling anxious? What is the philosophical meaning of life? What are some of the things they would want to do before they go? These difficult conversations between family and caregiver are never facilitated. 

You think the next generation is better prepared to handle these things?

I think, with the generation after this, it’s going to be largely commercial. Already, we are seeing instances of assisted caregiving. But then, it is going to take care of only a small percentage of the total population.

So, until we pump in resources proportionately for all strata of population, this is going to be a crisis, as the demographers articulate. The younger generation would not be able to hold the larger proportion of older adults.  

Considering our generation, most of us still have siblings. If you’re looking at our children’s generation, most are single children looking at two sets of grandparents and one set of parents—that means they have to take care of six senior citizens without any support.  

So, now is the right time and change things and it can be experimented in small ways. For instance, the focus should shift to workplace provisions for one sector and increasing government provisions for people living below the poverty line and the vulnerable sections.

Also, in terms of public health, we must emphasise on prevention and promotion. What can we do to promote activity? Why can’t there be a PHC that caters to the needs of specifically older adults? Tamil Nadu has a provision for older adults in the PHC, but how accessible is it?

Physical and mental health are interrelated. Say, I have been walking around freely but now I have a swollen leg and I'm not able to move.

There is pain, there is distress associated with the pain, and disability associated to the arthritis. Now I'm frustrated and impacts my mental health.

How can we create spaces where they can talk about what's going on in their minds? Do these spaces exist in the public domain? 

In Mumbai, there is something called the Adatha trust. They operate within the premise of the Mumbai University. So, senior citizens can walk in any evening and systematically get involved in activities like yoga or singing bhajans.

They communicate, share their stress and discuss how to overcome that stress. It’s as simple as that. It’s not a very clinical or therapeutic approach. But still, there is a kind of therapeutic elegance that's formed. There is a purpose, there is fun and there is a collective.  

Rather than only emphasising on geriatric mental health, we can also form kiosks or clubs, where people assemble, interact, do something meaningful and go back.

So, on the one side we look at prevention and promotion emphasis, and on the other, we must look at dementia, cognitive impairments, depression—what can be done for these aspects, even in the healthcare space?

But when community amenities for promotion are established, a very miniscule percentage will require this high intensity resource. 

Are there any proposals which have been sent to the state that are under consideration? 

The Ministry of Social Justice and Empowerment has formed committees recently. This can be the starting point, but they state also have to do the needful. Our study should not stop in the initial stages; we have to see this as a whole diverse community in terms of caste, class and gender, and come up with appropriate support mechanisms.