A while ago, my wife and I decided to move back to India to care for my aging parents. (ref blog: Life lessons on relocating to India: Six lessons from a six year old). This blog has my continuing musings on the topic of elder care in India.
Many of us take on the responsibility for parents and family members when they age. About a year ago my wife and I moved back from the US to take care of my aging parents. In the year gone by, I have been reflecting on my experiences with the growing cottage industry around elder-care in urban India.
A generation or two ago, it was quite common for joint families – three or even four– generations to live together. One would frequently come across middle class families with grandparents living with uncles, aunts, cousins and siblings with their kids. In many cases, the families would live in a large house, under one roof or in a compound with conjoint units.
Festivals and celebrations would be a joint affair, and there was an informal division of labor when it came to household chores. Some finances, resources and effort would be pooled in without much thought or effort since it was the norm and expected. The communal process was also designed to provide for care and support of children and elderly in the family. Even when families didn’t live together under one roof, they lived in close proximity – perhaps the same village or town – giving them a sense of belonging and being there for each other.
Demographic shift: two sides of a shifting coin
India is certainly a youthful country with a large population. With over 350 million 10-24 year-olds, India has the world’s largest youth population; and over 70 percent of Indian population is under 35 years. Thanks to improved access to medical care and increased affluence of the population, the life expectancy of senior citizen in the country continues to rise. Many seniors are also living well into their eighties and nineties, which bodes well for elders if the earlier social support model had continued.
In the past couple of decades, the Indian society has transformed. Rapid and widespread urbanization, migration of population from villages to cities, and emigration of the younger generation to western countries has changed the social fabric considerably. Younger generation of Indians are increasingly aping western model of independence and self reliance, leaving home as soon as they are ready for college, and then continuing to pursue their jobs and careers wherever opportunities beacon.
The logistics and expectations of senior care in India, however, has not kept pace with the change in the society.
In the west, the fragmenting of joint families was accompanied by an emergence of senior-care system across a wide spectrum. Care giving for seniors is a serious and lucrative business. Organizations and entrepreneurs provide services ranging from senior living apartments and condos, assisted living homes to a network of hospice and terminal care systems. This has led to a large network of service providers focused on various aspects of home-healthcare to meet medical and caregiving needs. These facilities are designed to accommodate people from across social, economic and demographic segments.
Senior citizen in the west willingly – or sometimes goaded by family members – move from one stage of elder-care to the next as their physical faculties and abilities change as they age. Such changes are generally accompanied by downsizing of one’s house, assets and other amenities of life.
One can argue that much of the senior-care is ‘outsourced’ without emotions and encumbrance by family members. The society has begun to accept this as a norm and people begin saving for their own retirement and old-age. In some western countries, personal savings are supplemented by an advanced system of social security that comes handy for a variety of senior needs.
Emergence of old-age care in India
Young, Indian nuclear families who opt to live away from extended families and hometowns still feel obligated to support their elders but are unable or unwilling to take on such responsibilities that might weigh down their lives and careers. As the society transforms, the Indian middle class is beginning to explore a wider range of elder-care facilities to accommodate their eclectic needs. This translates to an increased demand for elder-care and home-care services.
Old age homes, that in earlier generations were the last refuge for poor and destitute are starting to transform. Many “old age” homes are being designed to cater to the needs and desires of the urbane, affluent middle class and also the needs of the NRI community. Some of them advertise modern amenities, 24-hour care and security along with communal facilities including access to nursing and medical care. Some facilities in larger cities also advertise “elder day care” where one can drop off elders during the day to engage and entertain with fellow seniors.
Builders and property developers are beginning to capitalize on this opportunity to develop flats and communities for ‘senior living.’ The sweet-spot is the relatively affluent class of empty nesters and newly retired senior citizen in their sixties who are looking to downsize from their flats and villas to planned senior communities.
Such planned senior-living communities and old-age homes address only a small segment of the needs, especially since senior citizen have unique health and other challenges. Much as we desire to maintain good health as long as we live, nature and age takes its toll. No two seniors age in the same way. Disease ranging from benign aches and pains and temporary loss of memory to more serious cancers can derail the best laid retirement plans. Ailments that incapacitate and cripple elders can be excruciating. Such a crippling of physical faculties can affect the morale of the elders, while also draining the energy and resources of the families that unwittingly get sucked into the role of caregivers.
My father, a proud veteran of the Indian Air Force enjoyed a relatively good health well into his seventies after retiring from service. He and my mother enjoyed their golden years living alone in an independent house and frequently traveled to temple towns across South India. All this slowed down after my dad was diagnosed with Prostate Cancer – in itself not a life-threatening condition. However, in quick succession he was also diagnosed with Parkinsons, that began impacting his motor skills and physical movements. While he was mobile and active during the day, he needed help with diaper change at night and to escort him for his morning walks. After a few phone calls and quick research, I engaged a caregiver from an independent agent who had provided a similar service for a relative’s family.
The middle-aged lady, Kamala, would come at around 8 in the evening and spend the night at home and after the morning walk and breakfast with dad, would leave. Her temperament was well balanced and she brought in a rich background in caregiving from her previous experiences. This setup continued for about a year, before my dads’ condition abruptly took a nosedive after a mild stroke, when he was hospitalized. After a few weeks in the hospital, he was discharged and advised homecare where he continued to be bedridden.
We realized that the night-caregiver wouldn’t be sufficient and that Kamala alone wouldn’t be able to manage my father’s advanced needs. After additional word-of-mouth research, I decided to engage a live-in caregiver from another small organization managed by ex-servicemen.
A good caregiver can certainly help with basic needs including feeding, bathing, toilet and other requirements of the elder. However, I realized that even engaging a full-time caregiver does not let a family abdicate its responsibilities that can include managing the logistics. For instance, I still have to manage the procurement and administration of medicines, medical supplies and other sundry needs. My wife and mother manage the domestic chores that now include care and feed for my father and also the needs of the caregiver. After all, a full-time caregiver becomes an extended member of the family, and also has needs to be cared for.
Cottage industry around Senior care
My experience in hiring and managing caregivers has given me some insight into the highly fragmented cottage industry around senior-care. The vast majority of elderly-caregiving in India, is still managed by family members. However, nuclear families like mine are realizing that they are ill-equipped to take on the complex chores involved in supporting aging parents while also managing their own lives and families.
Given the unique needs of home-care in India, an entire cottage industry has sprung up in this sector. Most caregivers are either individuals or small ‘agencies’ employing a few people who get clients via word-of-mouth referrals. Unlike most other menial services, caregiving for the elderly and infirm is a highly personalized affair. The needs can range from simple care-and-feed to more unique care depending on medical and other health-related conditions. This requires a person with empathy who can manage - and sometimes challenge - the whimsical needs of frail elders. They also need the physical and emotional resilience to manage highly stressful situations; and sometimes pushback doting family members who might have their own demands.
Other small businesses are also emerging in this segment, offering a variety of services. Some organizations offer home visits by nurses and doctors while others offer in-home visit by lab-technicians for blood and other sample collections. Many ecommerce ventures offer online ordering of drugs, medicines and other medical supplies needed for in-home caregiving.
Bottomline: The newer generation of elders, caught between rapid urbanization and prevalence of nuclear families is realizing that they need to be more involved in planning for their own sunset years and many not have the social support previous generations enjoyed. However, without an advanced network of providers catering to needs of seniors, those who can, still fall back on their families. It still takes a village to care for an elder; though an increasingly affluent middle-class has to pay for the village!