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The fullness of life
by Jeremy Seabrook
The International Red Cross and Red Crescent Movement has always acknowledged the elderly among vulnerable populations in its policies and programmes. But the unprecedented growth in numbers of elderly people on earth creates a different order of vulnerable people. Demographic changes over the next generation may be profoundly disruptive, but imaginatively managed, they can enhance and enrich societies. Influencing perceptions of the elderly and their contribution to the world offers the Movement new possibilities.

An old man lived with his son, daughter-in-law and grandson. The son and his wife considered him a burden, and didn't want an old, physically incapable person in their home.

They decided to get rid of the problem. The son took his handicapped father in a basket and set out for the jungle, planning to leave the old man there. The grandson, observing this, said: "Father, be sure to bring back the basket." "Why?" asked the father. The grandson replied: "Because I will need it when you grow old." (Bengali folk story).

In an industrial town in northern England, an old man became a burden to his family. Unable to support him, his son decided to take him to the workhouse. The father was unable to walk, so the son carried him on his back. As they climbed the hill to the workhouse, the son paused on a wall to take a breath. The father said "Why, this is the very spot where I rested when I took my own father to the workhouse 40 years ago." The son turned back and went home. (Industrial folklore, Britain, 19th century).

The pain and problems of ageing show a surprising congruence through time and across cultures. While the changing demographic balance in the contemporary world is unparalleled, the dilemmas this poses are familiar.

Every month 1 million people in the world turn 60. By 2010 one in ten of the population of the globe will be over 60; by 2025 this will be one in five. By 2050 the proportion of over-60s will be higher than that of under-15s. Almost 60 per cent of the elderly live in the developing world; by 2020, this will rise to 70 per cent. Fifty-five per cent of older persons are women; among the over-80s, it is 65 per cent. Of course, projected figures may be contested, but the trend is clear. In the second half of the 20th century, 20 years were added to the average lifespan, raising global life expectancy to 66 years.

Meanwhile, birth rates are falling in many countries, the result of earlier efforts to slow population growth. In other cases, people are delaying the age at which they are willing to start a family, partly because in the rich world, "children are expensive", but also because young people want to pursue their careers and have a good time before assuming responsibility. Consumerism and individualism also contribute to elective childlessness, a factor in Western societies' failure to replenish themselves.

The implications of the statistics are just beginning to sink in and the issue has fuelled debate within governments, international agencies and non-governmental organizations (NGOs) as to how to deal with the potentially explosive problem. Alvaro Bermejo, head of the health department of the Federation, says the Red Cross Red Crescent, and more generally the humanitarian world, are on the whole "not good at long-term planning". He adds, "We respond to immediate crisis, conflict and disaster. To anticipate disasters and opportunities that haven't yet happened is more difficult for us." The ageing population is not only a disaster that need not happen, but with proper care, it can be turned to an advantage.



The bonds of family, so precious in old age, are gradually being eroded by economic development, globalization and, in some cases, conflict.
Rich resource

Until recently, the preoccupation of international agencies has been with children - children in poverty, traumatized by conflict and war, trafficked, enslaved or set to work. Now the focus is changing, from "too many" children to "an excess" of old people. The only constant is that people are seen as the problem. This is unhelpful. People, young and old, are always a potential resource.

Older people who maintain their health and vigour constitute a reservoir of skill and energy which can be deployed for the benefit of society. This is a truth which the developed world is rediscovering. The time of the passage of the over-60s into unproductivepassivity has gone. To some extent, the Red Cross and Red Crescent Movement has already tapped into this, relying on the good services of large numbers of retired volunteers. In the same vein, the French government has mobilized pensioners in an initiative to revive the pleasure of reading among schoolchildren.

However, as more women pursue a career, the energies of young grand-parents are devoted to caring for their grandchildren: this may mean the future flow of volunteers is at risk. Alvaro Bermejo believes that blood donors, who at 65 receive a letter saying their blood is no longer required, could be offered another health role, perhaps in caring for the vulnerable elderly, since blood donors have a strong sense of solidarity and concern for others.

The other side of the coin

To take a positive view of the capacities of the elderly is not to deny the problems that arise when the very old and dependent make up a rising proportion of the people in any society. Supports of kinship and family in South Asia, for instance, are seen by governments as relieving them of the necessity of providing welfare systems. These traditional security systems are under severe strain imposed by the development process itself. While international agencies constantly stress the need to strengthen and maintain such supports, economic imperatives are tending to undermine them.

The migrations and uprooting of people all over the world upset the demographic balance in local communities: there are villages in many parts of the world where the able-bodied have gone, leaving only the old and the very young, dependent on remittances. A majority of the world's elderly live in the countryside, but in Latin America, many have grown old in the barrios and favelas of the cities.

Development itself wages a war of attrition against older collectivities of family, kin, clan and neighbourhood. Indeed, the developing countries are the site of an untried experiment, the consequences of which are yet to be seen. Globalization imposes great stress on the fabric of human belonging. If governments are unable to provide social security, while kinship networks are extended to breaking point, how is the gap to be filled?

NGOs intervene in one form or another; the contribution of religious charities is not negligible. There is great potential for the Red Cross Red Crescent to address the results of these developments. In the slums of Khartoum, the Sudanese Red Crescent, with HelpAge International, is not only offering care to the elderly, many of them displaced by war, hunger and poverty, but also has a programme of loans and microcredit for older people to set up small businesses, earning an income and renewing their self-confidence and status in the community.

Many National Societies in the developed world have identified the elderly as a matter of concern: Spain pioneered the use of alarm systems to help the elderly remain in their homes, while the American Red Cross, with its Caregiving Nurse Assistant Training Program, trains 10,000 people annually, with special regard for the critical needs of the elderly population. The American Red Cross is currently contemplating extending this programme to include family carers of vulnerable and dependent people.

Alvaro Bermejo is critical, however, of the "service provision" to which many National Societies have limited themselves: "The target populations must themselves become more involved, and we should be supporting a rights-based demand. Are we going that way? Or are we just competing with other service providers - NGOs, governments, the private sector? Elderly people should not just be the target, the object, of our interventions; they should be at the centre of what we do and how we do it."



Percentage of world population over 60 and under 15.

 

Numbers of over-60s.

A women's issue

Common to both rich and poor countries is the greater longevity of women. In the US, one in three households consists of a single person, many of them older women.

More and more people of retirement age in the developed world are taking care of a spouse or their own very elderly parents. A woman in her 70s in an English town says, "I looked after my mother till she died at 93. I was then 70. She had a heart condition, she became incontinent. She often cried out in her sleep. For the last ten years of her life, I never had a night's rest. I was always half-listening, alert to her needs. Even now, I sometimes wake up, trembling, thinking I heard her call, although she died six years ago."

It is impossible to exaggerate the value of lone individuals taking care of the very old. Yet they often remain invisible, as do many struggling with dementia, Alzheimer's, incontinence and the need for constant nursing. It is easy for the unpaid contribution of elders, especially women, to be overlooked or taken for granted as an extension of women's "normal" responsibilities.

To some degree the problem of isolation of the elderly is compensated, as the Red Cross in many European countries has demonstrated, with home visiting programmes which understand psychological and emotional needs as well as the mechanics of physical caring. This is even more urgent in places where conflict and catastrophe, social and ethnic violence have stranded some of the most vulnerable without support, and in societies which discriminate against women.

Unable - or unwilling - to flee the ravages of conflict, an elderly Chechen woman salvages the treasures of her past from the ruins of Grozny.

 

Economic imperatives

In Asia, Africa and Latin America,survival of the elderly depends on employment. As it is, a majority of the 400 million elderly in Asia and Africa - farmers, labourers, rickshaw drivers - work until they die. They have been poor all their lives; their labour has been exhausting and excessive.

The issues in the rich world have already appeared with the starkest clarity. Social security systems cannot sustain growing numbers of beneficiaries supported by a declining proportion of contributors. Between 2000 and 2050 the ratio of older people to those of working age will more than double.

One way of dealing with the old-age dependency ratio in the West is the reinsertion of the young-elderly (55-70+ group) into the economy. This is a delicate issue, since recent experience has been the opposite - the exclusion and early retirement of the elderly. How this may be reversed requires greater attention than it has so far received. In any case, rapid technological change has made existing skills obsolete, and devalued the knowledge of an older generation.

Ali Taqi works with the International Labour Organization (ILO), concerned with the employment of the elderly in developed countries. "Social security systems, especially pensions, cannot support the numbers in need. It is vital that working life be prolonged, particularly as there is a critical shortage of labour in some industries. On the other hand, many people regard retirement as a just reward for a lifetime's work."

 

The Finnish experience

The Red Cross in Finland developed its programmes for the elderly over a long period. After the Second World War, the National Society worked not only in reconstruction, but also with the elderly displaced from the area annexed by the Soviet Union. During the 1950s, a system of home visiting to the vulnerable elderly was established, using volunteers to befriend them and to help with shopping, cooking and hospital visiting. This programme expanded, and the Red Cross gave training and salaries to home helps. In the late 1960s, this professional service ceased, since as Finland became richer, the government extended the welfare state and considered NGOs should not be involved in delivering such services. Red Cross intervention was reduced to friendly visiting of the elderly. The recession in the early 1990s led to cuts in government spending, and the Red Cross once more stepped into the breach. The work in this area grew, imaginatively supplementing care in the community which the government could no longer afford. The system has been based upon a network of about 10,000 volunteers, the majority of them mature women. It has been subsidized in recent years by funds from the national lottery.

However, since many of the older generation in Finland are no longer poor, and can afford to pay for care, private enterprise is now capable of providing such services, which are also increasingly professionalized. Local authorities will still be responsible for care, but they will buy in from elsewhere - the private sector and NGOs. The Finnish Red Cross has responded to the changed situation, and is now creating a business plan for service delivery, whereby volunteers will be backed up by professionals. With more than 15 per cent of the people over 65, the demand is growing; the level of provision remains below that of the time before the recession. The Red Cross will at the same time carefully monitor the quality of services.

Certainly, existing volunteers serve as an inspiring resource. In Esboo, close to Helsinki, there is a community "village"centre, run by a retired librarian. This serves as a focus for activities for the elderly, and a base from which volunteers visit those in need, arrange hospital visits, provide psychological support to the bereaved and isolated and try to motivate the helpless. The impact upon volunteers of professionalizing services remains to be seen. Whether this represents a compromise of basic principles or a response by the Red Cross to a changing environment is a debate that will run through the Movement in the years to come.

A new role for the Movement?

The picture of increasing life expectancy is by no means uniform throughout the world. In the "transitional economies" of eastern Europe, where former welfare systems collapsed, many victims of the abrupt change to the market economy have been the elderly. In the Russian Federation life expectancy fell from 65 to 58 between 1987 and 1994; a result, in part, of the loss of state systems, but also of the abuse of alcohol, drugs and increasing impoverishment. This has been an aggravated version of the slower erosion of existing welfare systems in the rich market economies. In both, there is a growing gap which can be only partially filled by NGOs and voluntary and charitable organizations.

In Azerbaijan, 30,000 elderly people living alone have received Red Cross Red Crescent support; in the Czech Republic, 7,000 home-care nurses have been trained; in Croatia, the Red Cross provided relief, medical and psychological support to 10,000 isolated elderly people left to fend for themselves as a result of conflict. Indeed, in many other parts of eastern Europe and in the former Soviet Union, the Federation, ICRC and individual National Societies have been running assistance programmes to help the elderly and destitute to survive the harsh winters, providing them with food, warm clothing, shoes, blankets, mattresses, candles and medicines. For many of the beneficiaries, who have no other means of support, these basic goods are often the difference between life and death.

This poses a sharp dilemma for the Movement. In a situation in which governments are privatizing and retreating from universal provision of welfare services, how appropriate is it for the Red Cross Red Crescent to step into the breach created by the exposure of vulnerable populations to the rigours of the market?

On another front, in parts of sub-Saharan Africa, life expectancy has been reduced by almost 20 years by AIDS. In 1999, 13.2 million children lost their parents to AIDS; and in ten countries, life expectancy has fallen to 46.3 for women, 44.8 for men. In Côte d'Ivoire, Kenya, Uganda and Malawi, grandparents are taking over the care of orphaned children. Just when they might have expected their own children to look after them, they must continue to work in the fields as well as bring up a new generation. In such circumstances, there is no agonising over the role of the elderly: AIDS has summoned them to a vital function. But it is a result of the direst necessity. Bekele Geleta, head of the Federation's Africa department, believes the capacity of elders to cope with the enormity of AIDS should not be overstated. "To talk of sex has been taboo in many societies. The wisdom of elders has no relevance in this situation. To expect a grandmother with no work to look after 12 grandchildren is too much for anyone to bear." Alvaro Bermejo says of the debate within the Red Cross Red Crescent over care versus prevention of AIDS, that you can't do prevention if you don't do care. He says, "It won't save lives, but they'll die a different death." This is a useful metaphor for the issue of growing older - you can't stop ageing, but you can age positively.

Affirmation of continued usefulness or harsh reality, economic activity late into life is for many in the developing world a necessity.

 

The elderly in crisis

During emergencies - war or natural disasters - the elderly suffer disproportionately. The less mobile cannot even become refugees. Left behind in war zones, they face bombardment and, as occurred in Kosovo, vengeful harassment. Images from Chechnya of elderly women, emerging from cold basements to pick their way through rubble in search of basic provisions, remain an enduring symbol of the sufferings of the old. As in conflict, in "natural" disasters - Hurricane Mitch, the 1999 cyclone in Orissa, to name some recent examples - the infirm often remain to live or die according to chance.

The Red Cross Red Crescent, as one of the few agencies to remain in the dangerous places of the world when others have departed, has always fulfilled a unique role. Jennifer Inger has been working with the Federation in Bosnia and Herzegovina, where the Red Cross home-care programme, which is assisting 15,000 vulnerable elderly throughout the country, has been, literally, life-saving. "The situation of the vulnerable elderly in Bosnia and Herzegovina is worse now than it was during the conflict," she explains. "There is no normal community support; families are dead or fled; the government cannot provide even the most elementary services. The Red Cross is the biggest non-government provider of social services in the country." Through cross-entity community contacts activities, the elderly have themselves become agents for reconciliation between Serb, Croat and Muslim communities.

It seems that all the rhetoric of "giving" the elderly a purpose, integrating them into society, remains theoretical until harsh material circumstances call forth their otherwise neglected powers. If this is true, it is a sobering prospect for industrialized countries, puzzling over what to do with their ageing peoples. Can a role be found for them without a major catastrophe?

The wisdom of age

Many societies where elders retain power are poor and conservative. In Somalia, they have been one of the few guarantors of civility in a country where central authority collapsed into competing clans. The recent re-establishment of a traditional assembly, which elected the president, was initiated by traditional elders, together with support from civil society. Thomas Merkelbach, ICRC desk officer for the Horn of Africa, says they hold a moral power superior to that of political and military leaders. "The town of Belet Huen, where tension had been held in check by a respected elder, became a site of conflict when he died early this year, because there was no one to replace him. The municipality is now divided."

Josephine Shields, of the Federation's disaster preparedness department, states that "in the Caribbean, the elderly are regarded as precious, and all Red Cross programmes recognize this - there is always a component for the protection of old people." A cooperative convergence exists in the small societies of the Caribbean, where governments, NGOs, churches, families, neighbours and the Red Cross all do their part.

"We also respect the old because when preparing for disasters, we call upon their experience: they remember how high a river has ever risen, what are the signs, the extent of damage to be expected."

The experience of the rich societies has often been the contrary of this. AGE CONCERN in the UK drew attention to the increasing number of assaults "by the young" upon the elderly. Far from being regarded as repositories of valuable wisdom, the old are seen as competitors for scarce resources. This also affects sections of the middle class in the South. The director of Age Care in New Delhi said, "Many young people resent grandparents sharing the family home. When there is a party, the old people go without supper, they are required to absent themselves from the festivities. They occupy rooms that grandchildren want for their video games, TV sets and toys."

In many societies, too, the authority of older people has been subverted by "development" and "modernization". Older knowledge-systems have decayed or been overtaken. There are other factors, of course. Lengthening life expectancy has also damaged the respect formerly accorded to the relatively few who survived into old age. Venerability is a consequence of scarcity: in an ageing world, it is in steep decline.

An Egyptian Red Crescent volunteer personifies the commitment and experience of the older people who constitute a valuable resource for the Movement.

The benefit of foresight

The growing proportion of the elderly in the world, by the scale and magnitude of the issue, presents the Red Cross Red Crescent with scope for new interventions, but it also raises new questions. What should be the response by the Movement to a private sector capable of answering the needs of the well-to-do elderly in the developed world on a profit-making basis? Should National Societies step into a role vacated by governments unable or unwilling to fund adequate care of the most vulnerable? What kind of economic activities can be devised for the elderly in developing countries to enable them to contribute to family income? Should the Movement go beyond service-provision, to motivate its members in the interests of a rights-based approach to the elderly? How can fresh sources of volunteers be tapped, given the claims upon the time of those mature women who have always been primary actors in the social programmes? How can the reservoir of unused talent and energy in the young elderly be harnessed for the work to be done?

These questions, in a world of increasing mobility, where family networks are breaking down, where the gulf between rich and poor continues to widen, are not academic; and no doubt, the Movement will respond to them according to the priorities of the moment. The ageing of the world is not a disaster; but without the vision and energy to transform the wisdom of time into a benefit for humanity, it may become one - not a sudden catastrophe, but a disaster by stealth and by omission.

Jeremy Seabrook
Jeremy Seabrook is a freelance journalist based in London.



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