As young families move to pursue modern jobs in the cities and life expectancy increases, India struggles to address a growing, heartbreaking gap in elder care.
Story and photos by Katya Cengel, World Ark contributor
She was 18.
As a widow living in the rural village of Piplai in northern India, Kanwar understood there was nothing left for her in this life. She knew, she said, that she would “live like a destitute and die in the same manner.”
She never remarried. She couldn’t. Kanwar belongs to the Rajput caste, an upper caste, legend holds, descended from ruling Hindu warriors that does not allow widows to remarry. Rigid caste rules also kept her from working outside her home. She supported her young daughter by selling her land and accepting handouts from her extended family.
Her daughter married and moved away long ago. The land is gone and Kanwar uses the crumbled stone home, she lived in as a newlywed, to store dried dung cakes to be used to fuel fires. Now 60, she has white hair and creased skin. She wears a pink sari and a clumsy pair of black glasses. Two months ago she gave 100 rupees ($1.99) to a middleman for cooking gas. The gas has yet to arrive and the 500 rupees ($9.95) a month pension she receives from the government is barely enough to cover two meals a day.
Few visit the single-room structure adjacent to her old home where Kanwar lives. She is a widow without a son, both bad omens. The village girls sometimes collect kindling for her, but she must fetch her own water from a nearby hand pump. It is a difficult existence, but one that is not uncommon for India’s growing elderly population.
When Kanwar was born in the early 1950s, the life expectancy in India was 42 years. In 2011, it was 65.
Increased life expectancy and improved child survival rates, coupled with declining fertility and mortality rates, are causing a demographic shift in India, one with a progressively increasing number of elderly. A decade ago, those over 60 accounted for 6 to 7 percent of India’s population, said Valerian Pais, program manager of the nonprofit HelpAge India’s Mumbai office. Today they make up 9 to 10 percent of the population, and by 2050 they are expected to account for 20 percent, he said.
The shift has caught the government and society unprepared, said Syam Prasad, a post-doctorate fellow at the Indira Gandhi Institute of Development Research in Mumbai whose work focuses on India’s elderly. Unlike in developed countries where a social security system is in place to care for the elderly, there is no such system in India, Prasad said. The majority of the population, he explained, work in the private sector, rarely making enough to save for retirement. The sector also lacks an organized pension system. It is widely reported that only 10 percent of the elderly receive government pensions. In addition to retired government employees, elderly who fall below the poverty line and have an annual family income of less than 18,000 rupees ($354) or consume less than 2,000 calories a day, are supposed to receive a pension, said Prakash N. Borgaonkar, director of HelpAge India’s Mumbai office. But securing one can be difficult. Government workers are supposed to travel to rural areas to collect this data, but those interviewed said that does not happen. Even those who do manage to get on the pension list, like Kanwar, struggle to make it on the money they are allotted. In the past their families might have helped, but today, migration, modernization and urbanization are increasingly breaking joint families into nuclear families.
And the challenges will continue to grow as the population ages.
“In 2040 there will be 324 million elderly; that means only three countries will have a total population more than the population of our elderly—China, the U.S. and Pakistan,” Borgaonkar said.
Government and non-governmental sectors are working on ways to meet the need. A national elderly policy was established in 1999, and a welfare act requiring that adult children monetarily support their impoverished parents was passed in 2007. However, districts have been slow in setting up the tribunals where the elderly can make claims without having to pay expensive court fees. Individual states, including Maharashtra, are working on their own policies on everything from mobility issues to elder abuse.
HelpAge India has lobbied for the passage of such bills and worked to involve communities in the effort. Like HelpAge India and other nonprofits, Heifer India serves the elderly by improving the situation of entire communities. Heifer India focuses on women-centered self-help groups that encourage members to pool their resources and support each other on small ventures that will help support their extended families. Heifer’s livestock and agricultural gifts and trainings allow rural families and communities in Rajasthan, Bihar and Odisha states the extra cushion to help them to care for the more vulnerable members of society like the young and elderly.
Changing Definition of Home
When K.L. Sharma established the Indian Gerontological Association in the late 1960s, few in the country knew what gerontology was, he said. At the time, India’s elderly population fell below the 7 percent required to define a population as having begun aging, said Sharma, a retired psychology professor who lives in the northern Indian city of Jaipur.
Things have changed rapidly since then. Improved medical care and sanitation coupled with the absence of war have increased lifespans dramatically, explained P.K. Dev, vice president of the Gerontological Association. Though the health trends should be good news, the government did not have the corresponding infrastructure in place to cope with the new challenges. Its limited resources were being devoted to the support of impoverished mothers and their babies. That focus has helped improve child survival rates, Dev said.
At the same time, the family structure that once cared for the elderly is under threat. As recently as the 1990s, when the government approached Sharma about establishing more homes for the aging, he told them not to bother because families cared for most of the elderly.
“Now I’m of a different opinion,” Sharma said. “I think now we need oldage homes.”
In Hindu tradition, sons care for the elderly, Prasad said. But modernization, globalization and urbanization mean many young people are abandoning rural villages for work in cities and abroad, putting the tradition of three generations living under one roof under increasing threat.
Maria Dias stays with her two daughters occasionally, but for a reason she will not, or cannot, explain, she said, she can’t stay with them too long.
“I miss them, but what to do?” she said.
Marie Netto isn’t exactly sure why she chose to come here 28 years ago, but it probably had to do with the fact that she didn’t get along with her in-laws and didn’t want her daughters-in-law to suffer under the same circumstances. Netto, who is 86, struggled to recall certain words during a visit.
“I’ve forgotten now; I don’t talk to anyone or anything,” she said. Her husband and three sons are deceased, and her daughter lives in Australia.
Netto is well taken care of at All Saints, but her body aches and she routinely asks God: “Why do you keep me so long?”
Thirty years ago maybe 10 percent of the elderly population lived in old-age homes, said All Saints’ superintendent Sharda Joel. Now, she said, the homes are “very badly needed.” In Mumbai there are only 120 to 150 old-age homes for 1.1 million elderly, Borgaonkar said.
All Saints takes women of all faiths and charges families that can afford it— about 15 to 20 percent—a 30,000 rupee ($590) donation, a 10,000 rupee ($196) medical fee and a monthly fee of 1,500 rupees ($29). The medical fee is collected at admission because sometimes families “don’t reach out” after admitting their mother, Joel said. Although the 55 women who stay at the home are outwardly cheerful and upbeat, they are also sad.
Because of the lower status women occupy in Indian society, elderly women have always been particularly vulnerable, leading to the establishment of homes such as All Saints that are devoted solely to their care. Elderly men may have savings or property that can help support them, but the traditional role of women as workers inside the home means that many elderly women lack income, savings or property and are more reliant on others for their care.
“All these years they have served for the children, how they will be happy?” Joel said. “They will not be happy. They want to stay along with their children.”
Pune’s Matoshri Old Age House has 80 seniors on its waiting list. Residents sleep three to a room and keep their personal belongings in lockers. On winter afternoons they gather outside, the men, including Gajanan Joshi, in one area, and the women in another. Joshi is 91 and has four sons and one daughter. He worked as a city government clerk for 32 years and can remember the exact day he arrived here—Nov. 2, 2011—but he has difficulty explaining why he came. Tears were the only answer he could provide.
About half of Matoshri’s 120 residents stay for free. Although the government established the home and was supposed to fund it, it receives no money from the government, said Jayant Savlekar, who manages the home. Instead it must depend on private donations. This was confirmed by a state government official who explained that the political party that established Matoshri is no longer in power, and the political party that replaced them chose not to fund the home.
“So that's why you will find most of these old-age homes not functioning. They have closed,” the official said.
Traditionally political parties have not paid much attention to senior citizens because they provide the parties little benefit. In India, caste is still a major factor in elections, so political parties pay more attention to platforms that benefit certain castes rather than a population like the elderly that is made up of many different castes.
In 2011, more than a decade after the central government established a National Policy on Older Persons, only seven of the country’s 35 states and union territories had partially accepted the goals it defined, such as expanding social and community services for the elderly. The situation is no better when it comes to the 2007 “Maintenance and Welfare of Parents and Senior Citizens Act” which requires that adult children provide monetary support to impoverished parents. HelpAge India found that only three states had put the act into practice almost three years after it was passed by parliament.
Maharashtra state, which encompasses both Mumbai and Pune, is expected to pass its first state senior citizen policy in the near future. They are working on amendments that would require buildings to add ramps and elevators to be more senior- and handicapped-accessible, said Dinesh Waghmare, secretary of the state’s social justice and social welfare department, which handles elderly issues. The state is also looking at programs that would use volunteers in partnership with the police to check up on homebound elders. But there is only so much the government can do, said Waghmare, whose department also handles other groups such as women and children.
“Government does not have that kind of funding to support all senior citizens and give all facilities to them,” said Waghmare. “Community involvement is a must.”
The impoverished are theoretically able to receive medical care at government institutions, but access is often difficult, especially for the elderly who must wait in the same long lines as everyone else and see doctors who are seldom trained in geriatrics, Borgaonkar said. HelpAge India has partially filled this gap with 74 mobile medical units that provide a doctor, pharmacist and free medicine to specific locations around the country.
Few of the seniors who visit Dr. V.R. Srinivasan’s converted ambulance in the Mumbai slum of Laldongar know their age. Nivruti Sadu Gaikwad and his wife, Radhabai, are in their 70s. They raised 10 children together, six of whom are still living, but none of whom support them, they said. Nivruti’s plastic glasses are tied on with a string and his wife’s arms are dry and knobby. Like the majority of India’s elderly, Nivruti worked in the private sector, in his case as a laborer, and does not receive a pension. The couple are poor enough to qualify for a government pension, but they do not know how to get one. They have been visiting the mobile medical unit once a month for almost as long as the 20 years it has been coming to the area. Radhabai is treated for asthma, and her husband receives medicine for stomach pain.
Sukhdev Thorna can barely walk up the back steps of the old ambulance the mobile unit operates from. She is in her mid-60s, with a sweet round face and legs hobbled by arthritis. Her husband is dead, and due to mobility issues she is no longer able to work as a cleaning woman. When Dr. Srinivasan asked about her living situation she broke down. She insisted her tears were not from sadness but from happiness that the doctor had talked with her.
“Nobody talks to me or asks,” she said. “This is the first time somebody’s asking about me.”
HelpAge India encourages students to advocate for the elderly. Educating the youth about the importance of caring for the elderly and encouraging families to maintain the joint family system that supports them best are the organization’s latest plans. Yet most of HelpAge India’s efforts focus on urban centers where they can help the most people.
Heifer International works in rural communities to establish gender equity and improve conditions by promoting small female-based self-help groups that support each other economically and socially, explained Abhinav Gaurav, technical liaison officer for Heifer India. Heifer supplies women in the groups with livestock and seeds and trains them in agricultural practices and animal husbandry. Additional trainings on social and economic issues, literacy and hygiene are offered, and several women are trained to serve as community animal health workers, helping serve the community while also improving their own financial situations.
“Development is not just about distributing livestock or physical input, it’s about transforming people and producing a deeper level impact,” Gaurav said.
Rajesh Singhi, executive director of Ibtada, one of the organizations Heifer partners with in Rajasthan state, said several self-help groups honored local elderly with useful gifts such as shawls last year. By improving the economic situation of women, the whole family prospers, he explained.