Islamset - Tradition and the future in India

The social and physical well-being of the elderly population is becoming an important issue for India. At present there are 55.3 million people in India who are over 60 years of age, which is 6.55% of the total population. The number is projected to increase to 75.93 million by the year 2001, representing 7.7% of the total population. The current decline in fertility and increase in life expectancy will continue to enlarge the elderly population. The proportion supported by their children, which was 80.8% in 1971, is projected to fall to 50.9% by 2001.

Rural and urban differences

There are significant socioeconomic differences between the urban and rural elderly in India. More than 80% of those aged over 60 live in rural areas. The rural elderly are older than the urban elderly, but have little access to tertiary care services. In the rural areas 6% of the women are elderly, in the urban areas 5.1 %. While 78.2% of the elderly men are currently married, thus having the support of the spouse, 64.3% of elderly women were widowed, and most of them are dependent. A large workforce exists in the rural informal sector: 70% of rural elderly men work, as against only 48% of urban elderly men. The health care services also differ significantly in rural and urban areas, with emphasis on primary health care in the rural areas, and tertiary care in the urban areas.

The medical problems reported by the elderly are mainly related to chronic disorders. Coronary heart disease is the leading cause of death in the elderly. Visual and locomotor disabilities are widely reported. In a rural community survey made by the Indian Council of Medical Research, only 20% of those inter- viewed said they had no medical problems. Geriatric subjects presented with five or six symptoms simultaneously, and had two or three diagnoses. Health problems were as follows: visual (65% of the sample), locomotor (36%), respiratory (10%), skin (8.5%), central nervous system (7.4 % ), cardiovascular system (6.3 % ), and hearing (5.8% ). On the positive side, only 1.1% had psychiatric complaints.

Health services

The Indian Council of Medical Research has shown that geriatric clinics can be set up successfully at the primary health centres in rural areas. The existing paramedical staff can be trained to recognize the important physical illnesses and find an appropriate medical, family or social intervention. Sleeplessness, vague bodily pain and backache responded well to intervention by health workers, while other symptoms like visual handicap, giddiness and pain in the joints showed only marginal improvement.

Psychosocial aspects of family integration and social integration could also be improved with intervention. In the rural areas, 10% said they felt isolated from their families while 11.6 % were actually living alone. Lack of family integration occurred even among those living with the family, and conversely, those living alone did not all feel isolated. In another study, elderly subjects attending psychiatric outpatient departments were observed to lack family and social integration. Depressive illness was the most common disorder, and patients responded well to intervention.

Appropriate screening and referral would greatly decrease the load on tertiary care services for the elderly, which in India are sadly lacking. Some hospitals do have geriatric outpatient services, but very few have inpatient facilities earmarked for geriatrics. This may be because the Indian elderly at present are mostly in the "young elderly" group (60-75 years old), in which there is little demand for long-term health care. A study on those attending a geriatric clinic in a rural primary health centre found that 58% required referral for medical care, 5.3% for psychiatric care, and only 2.3% for inpatient admission. In a countrywide survey made by the National Sample Survey Organisation, only 5.4% of those above 60 years of age reported being immobile.

General hospitals and departments of medicine continue to cater for terminally ill patients. Several forums have discussed the need for more emphasis on geriatric medicine and management in India. The public health system needs more centres and specialists in this field.

Elderly Indians are not easily moved to seek hospital care-on average, the time between becoming eligible for institutionalization and accepting it is 9.8 years. Health insurance and other support measures for the terminally ill are available for those who have worked in the organized sector. The majority of elderly who are ill are looked after by their families. Even today, the younger generation in India see it as their responsibility to care for their elderly, and they are under social and cultural pressure to do so.

Tradition

In the Hindu culture one prepares oneself for old age by adopting the disengagement theory. This stage of vanaprastha in a man's life requires him to give up his authority over family and property, and devote his time to self-realization. Such cultural traditions play an important part in the high level of life satisfaction found among elderly Indians. Indian social norms not only call for the proper care of the elderly by the family and the kinship group, but also define their status with regard to most family matters. Therefore, old age was never seen as a social problem in ancient India.

In contemporary Indian society, however, the position and status of the elderly and the care and protection they traditionally enjoy have been undermined by several factors. Urbanization, migration, the break-up of the joint family system, growing individualism, change in the role of women from being full-time carers, and increased dependency status of the elderly may be cited. There is also a generation gap in terms of education, aspirations and values, and the allocation of resources to different members of the family. Often the family is unable to meet the financial, social, psychological, medical, recreational and welfare needs of the elderly, and needs help from supporting services.

Old people's homes do not appear to be the answer for the majority of the Indian elderly. Of the rural elderly who were questioned, 33.4% suggested that such homes should be started in villages, but only for those who In the census of 1981, 65% of the country's elderly men and 14% of its elderly women were listed as workers. were destitute and lonely. Institutions such as ashrams may be suitable for such cases.

Increased recreational activities and spiritual discourses were among the suggestions made by the elderly for themselves.

The responsibility of the State for its senior citizens is enshrined India's Constitution. It includes pension schemes, but these are applicable largely to the organized workforce. In the census of 1981, 65% of the country's elderly men and 14% of its elderly women Were listed as workers. Thus a large proportion of elderly remain economically active. Of the non-working elderly, only 23% of the men were retired pensioners; 69.4% of the men and 52% of the women were dependent.

Steps to be taken

A workshop on the public health implications of aging in India was organized in 1993 by the Indian Council of Medical Research. Its recommendations included introducing the concept of geriatric care into hospital services, developing rehabilitation services for the disabled elderly, introducing principles of geriatric medicine in the undergraduate medical curriculum and organizing facilities for postgraduate training in gerontology at some institutions.

The terminally ill elderly are largely looked after by their families. Homes have been suggested for the elderly destitute and those living alone, but above all, commitment and compassion are needed, for without them no amount of facilities and infrastructure will work. Modernization is causing the traditional culture of family care to disintegrate. Every effort should be made to prevent the elderly from being segregated from the family. Family support for the elderly needs to be strengthened economically by the State. Western experience has shown that family and community support cannot be replaced by institutions and old people's homes.

Traditionally the elderly were seen as an asset and as the head of the household on whom the entire family could depend for guidance, coordination and advice. We should encourage people to continue this tradition.

The elderly represent a vast resource. Their experience, skills and wisdom should be recognized and fully used in each community and in society as a whole.