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Special Articles / T.K. Nair / Old Age in an Indifferent Society Social services for the elderly all over the world would fall into two broad categories: institutional care and community-based services. Institutional Care Institutional care in ‘homes for the aged’ emerged as a favoured form of care of the elderly by the state, and the religious orders and voluntary organizations when the family was unable, negligent or unwilling to provide care to the older members. Institutionalization isolates the elderly from their homes and the community, and hence is an undesirable form of care of the elderly. The dharmasalas, ashrams, maths and sadavartas, that have been in existence in India, are quite different from the ‘old age homes’. These are rest homes and retreats established by the religious institutions, erstwhile rulers, and pious individuals for the benefit of persons who wish to spend time in a religious atmosphere and to devote themselves to spiritual pursuits. They are numerous at pilgrimage sites and at other places of special religious significance to Hindus. Most such retreats are open to persons of all ages and both sexes, and many cater mainly to temporary visitors or pilgrims. But some are specifically designed for the longer term needs of older persons who intend to retire from active participation in worldly affairs and to concentrate on spiritual matters. Most of these retreats are supported by charitable donations, and provide accommodation and food to the residents free of charge, though some are intended for older people with means. Some accept an older person’s remaining wealth and property in return for life-time shelter and care. Elderly persons, who have no family or who opt to live among other older people in a religious atmosphere, are also looked after by these institutions. In the 1500s and 1600s, those who were not part of the domestic work force in England were considered to be “problems” ; these included vagrants, criminals, prostitutes, paupers, beggars, lunatics, orphans, the aged, and the sick. Estes and Harrington (1981) are of the view that the development of social control systems such as institutionalization to handle those who could not or would not work was the response of capitalism to deal with these ”problems” . The Poor Law of 1601, often referred to as “43 Elizabeth”, confirmed the responsibility of the parish (the local community) for the maintenance of the poor who were not supported by their relatives. The law distinguished three classes of poor: the able-bodied poor, the impotent poor and children. The able-bodied poor, called “sturdy beggars”, were forced to work in the “house of correction” or “workhouse”. The impotent poor were people unable to work : the sick, the old, the blind, the deaf-mute, the lame, the demented, and mothers with young children. They were placed in the “almshouse” where they were required to help within the limits of their capacities. If the impotent poor had a place to live and seemed less expensive to maintain them there,the overseers of the poor could grant them “outdoor relief”, usually in kind, sending food, clothes, and fuel to their homes (Friedlander, 1963). The Colonies adopted the Elizabethan Poor Law. However, in the United States of America, most of the almshouses and workhouses were established in large cities. In addition to outdoor relief in kind, the paupers were “farmed out” or “sold out” to the lowest bidder. A special type of farming out was the placement of widows, and infirm and aged paupers, for short periods, from house to house (Friendlander, 1963).The almshouse was the progenitor of the “home for the aged”. Many almshouses were, in course of time, converted into or rechristened as homes for the aged. Initially religious and voluntary organizations have started ”old age homes”. The almshouse finally became a “home”, achieving a “new status in the philosophy of scientific charity” (Haber, 1983). In the second half of the nineteenth century, organizations such as the “New York Association for Improving the Condition of the Poor” and their successors advocated institutionalization for all aged paupers. Their volunteers actively attempted to place every needy elderly person, including even those who resisted their charitable assistance, in institutions. By the beginning of the twentieth century, the segregation of the elderly into “homes” and “asylums” had begun to assume institutional form. Proprietary homes with high profit motives also began to flourish. Most of the developed nations have a type of residence that can be described as a home for the aged, which houses older people in need of assistance and provides help with meals and housekeeping as well as with bathing, dressing, and other self-maintenance functions. People with needs for daily medical or nursing care are not ordinarily placed in homes for the aged, but are put in nursing homes. Another common form of institutional care for the elderly is the mental hospital. The fourth type of institutional care for the elderly is the geriatric hospital, which is a central feature of the British care system (Lawton, 1982). Institutionalization represents the ultimate personal failure for the elderly and their family. “In fact, two-thirds of the elderly view institutions as the least desirable alternative possible, a sort of confession of final surrender, a halfway stop on the route to death” (Hendricks and Hendricks, 1977). There is adequate empirical evidence to prove that institutionalization is deleterious to the emotional health of the elderly, though some may have the benefit of a sheltered environment. The spectacle of older people living collectively, awaiting death away from family, is the ultimate tragedy of life (Puner, 1974).Townsend (1962), who made a well-known survey of residential institutions and homes for the aged in England and Wales, provides a mass of empirical data to portray the misery of many elderly residents in such institutions. His observations on the effects of institutional life on the residents are very disquieting. In the institution people live communally with a minimum of privacy, and yet their relationships with each other are slender. Many subsist in a kind of defensive shell of isolation. Their social experiences are limited, they lack creative occupation and cannot exercise much self-determination, and they are deprived of intimate family relationships. The individual has too little opportunity to develop the talents he possesses and they atrophy through disuse. He may become resigned and depressed and may display no interest in the future or in things not immediately personal. He sometimes becomes apathetic, talks little and lacks initiative. Townsend based on the strength of his survey data, asserts in an unambiguous manner that homes for the aged are not necessary. Ideology of Deinstitutionalization Two ideologies responsible for segregation of the elderly, according to Estes and Harrington (1981), are separation and medicalization. The first is predicated on the belief that older people are special and different, with needs requiring special and different old age policies and services; and the second is based on the premise that old age is a process of inevitable physical decline that is best treated by medical interventions. The ideology of separatism as the best way to approach the “old-age problem” has justified age-segregated programmes such as congregate housing, residential care and nursing homes for the elderly. The medicalization ideology, with its orientation toward individual rather than structural aspects of aging, has obscured an understanding of aging as a socially generated problem. The highly visible and growing economic costs of institutionalization, and the individual as well as the social costs of stigmatization resulting from segregated care led to a global trend towards deinstitutionalization. In the West, the pressure for moving mental patients “back to the community” in 1950s was so strong that it has become an important ideology, around which a diverse number of interest groups and professional bodies have converged. Social scientists have concluded that the institutions themselves were obstacles to the treatment of the mentally ill and urged community mental health programmes instead. Critiques of mental institutions such as Goffman’s (1961) “Asylum” brought about a consensus that mental hospital care was simply custodial care, and not therapeutic. The emergence of the deinstitutionalization ideology has profound influence in the advocacy for shifting the elderly from nursing homes and residential institutions back to the home and the community. Estes and Harrington (1981) are of the view that the pressures for deinstitutionalization of the elderly and the new ideology of “alternatives of institutionalization” in America are influenced by a combination of factors such as the growing concern of aging advocates, fiscal crisis in government, the powerful interests of the health care industry, and the efforts of health and social services agencies to command a large share of policy dollars. They warn that in the enthusiasm for deinstitutionalization and community-based services, the focus should not merely be on services. The political, economic and social factors that disenfranchise the elderly in society should not be lost sight of. Community Care of the Elderly Community care of the elderly in simple words is any form of care of persons outside of an institution by means of health and other social services based in the community. A number of research experiments have shown that it is possible to keep elderly people with very high levels of disability in the community (Means and Smith, 1985). Since there is not a better substitute for the family as a source of support for the elderly, community-based programmes have the advantage in facilitating the involvement of the families in enhancing the well-being of their elderly members and integration of the elderly in society. Community-based services in the Western countries include home-helps (also called homemakers, home-health aides), portable meals (or meals on wheels), friendly visitors, day care (also called geriatric day hospitals), respite services, and substitute family care (foster homes) (Beattie, Jr., 1976). Bell (1973) identifies five basic components of a community care programme in a given geographic region: health maintenance, home-help, mobile meals, transportation services, and counselling, crisis intervention, and advocacy. Community is an area in which a group of people live, or a group of people living in an area, or a group of people who have close ties or common interests. It is more than a physical place, it is a vehicle for social participation and collective action (Checkoway, 1988). ”Care” does not mean something given by an active younger person to a passive older person. The word can also mean a service which is given to a person by an organization. It also includes something which elderly people can actively take part in. Similarly, community care programme for the elderly does not at all imply that everything is done for them and they remain as passive recipients. On the other hand, the programme envisages the active participation of the older persons in decision-making and implementation.   Social work, according to the National Association of Social Workers (1973), is the “professional activity of helping individuals, groups, or communities to enhance or restore their capacity for social functioning and to create societal conditions favorable to their goals”. “Community care” has been a slogan in social work for about five decades. Probably the most clear element in the origins of community care is the movement for deinstitutionalization of the social services. Community care is also referred to as social care in the community. It is defined as “those aspects of social work concerned with enabling resources, which are or might be available, to be used more effectively in the provision of social services to clients” (Payne, 1986). Community care is concerned with all kinds of resources: personal, economic, social and political. Social workers are a significant part of the provision of community care because they help people to make effective use of their own personal resources and at the same time, they help community resources to provide for those in need. Community care rests on two basic premises: first, care is better provided by services organized in the community, rather than those based on institutions; and secondly, in enabling people to help themselves, dealing with the family as a unit is more important rather than its individual members’ problems (Payne, 1986). Eldercare Services in India Founding of Helpage India in 1978, and the World Assembly on Aging in 1982 have been responsible for creating greater awareness of the needs of the growing number of older persons in the country. Helpage India and its founding organization Help the Aged (United Kingdom) have made signal contribution towards the development of a variety of services for the elderly in India. Help the Aged was founded by a group of British businessmen, headed by the late Cecil Jackson-Cole, who was closely associated with the general development agency Oxfam since its origin as the Oxford Committee for Famine Relief during the Second World War. In 1960, the group had noted that no agency existed to meet the needs of elderly people in disaster situations, and discussions with the United Nations confirmed this lack of service (Tout, 1989). Thus Help the Aged came into being in 1960. In 1978, Help the Aged took the initiative to start an independent agency to work for the cause of the elderly in India which resulted in the formation of Helpage India as a registered society with Indian and overseas members in the organization. It mobilizes substantial resources in India for supporting various programmes for the welfare of the elderly through non-governmental organizations. Monegar and Rajah of Venkatagiri Choultries was the first institution for the care of the elderly in India. It has its beginning in the early 18th century, though the records about the Choultries are available only from 1782. Formation of Helpage India in 1978 marked the beginning of professional fund-raising and project advisory services, thus accelerating non-governmental efforts in promoting services for the elderly. The partnership between Centre for the Welfare of the Aged (CEWA), Helpage India and Help the Aged, UK, led to the development of a pioneering project at Chennai under the auspices of CEWA in 1979 to experiment with alternate elder care models to help strengthen the integration of the elderly in the communities in which they live through day centres, domiciliary care, family counselling, social work with elderly patients in hospitals, and income maintenance through assistance for self-employment, skill upgradation and group income-generating activities. The first day centres for the elderly in India were set up during 1979-80 at Chennai (Centre for the Welfare of the Aged), Mumbai (Family Welfare Agency) and Hyderabad (Association for the Care of the Aged). The role of the state in organizing welfare programmes for the elderly is marginal though some homes for the aged are run by the state governments. Welfare services for the elderly in India are mainly under the auspices of religious bodies and voluntary organizations. The Christian missionaries, particularly those belonging to the Catholic denomination, have been responsible for starting a large number of homes for the aged. “Little Sisters of the Poor”, a well-known religious order of nuns with its headquarters in France, maintains many homes for the aged in different states. Of late, the Hindu religious and secular groups are also starting residential care programmes for the elderly. References
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