Connect to share and comment
Poverty. Riches. The world's largest democracy. An ancient caste system. Bollywood. India is a land of contrasts, a booming new power that remains baffling to outsiders and insiders alike. The Shiva Rules is a year-long GlobalPost series that decodes the many mysteries of India's uneven rise in the 21st century.
India's 81 million elderly are already straining the health care system. What's going to happen when there are three times as many of them?
Editor's Note: The Shiva Rules is a year-long GlobalPost reporting series that examines India in the 21st century. In it, correspondents Jason Overdorf and Hanna Ingber Win will examine the sweeping economic, political and cultural changes that are transforming this nascent global power in surprising and sometimes inexplicable ways. To help uncover the complexities of India's uneven rise, The Shiva Rules uses as a loose reporting metaphor Shiva, the popular Hindu deity of destruction and rebirth.
MUMBAI, India — Maqbool Beg has been driving a rickshaw for 42 years. Now, at the age of 62, his children have grown, his beard has turned white, his teeth are red from years of chewing betel nut. And he suffers from high blood pressure. But he keeps on driving.
He needs the money. Thanks to inflation and the high cost of living in Mumbai, Beg has never been able to save. The 4,500 rupees (about $100) he earns a month make him ineligible for even a small government handout. Beg and his wife cannot rely on their sons, who earn even less working as a tailor and mechanic.
“Until I can no longer work, I will work,” he said, waiting outside a mobile health van in Bandra East, a suburb of Mumbai.
Beg is one of India’s 81 million elderly (technically, those over 60). While much of the attention on India’s population focuses on its young, the country also faces a rapidly growing elderly segment.
About half of India’s 1.2 billion people are younger than 25. India’s youth are often touted as the country’s best hope for one day surpassing China in economic growth rates.
Every year, India increases by the size of the population of Australia, and many blame nagging poverty on such stats. In some parts of India, local officials are taking extreme measures to try to curb numbers of children in families. In poor northern states like Bihar and Uttar Pradesh, an average woman still bears four children over her lifetime.
More from GlobalPost: India's injectable vasectomy
But, as with many things in India, the problem of too many children presents a contradiction.
It turns out that, overall, family planning efforts and rapid social development have resulted in lower fertility rates in most Indian states. Fertility rates have fallen from about six births per woman in the 1960s and 1970s to about 2.6 births in 2008, according to the U.N. Population Fund.
Smaller families and longer life spans have set India on a path to facing a massive population of elderly, say advocates for the aging and demographers.
Due to changes in social norms and the ongoing breakdown of joint families, much of this population of elderly will not have India’s traditional family system to support them. Furthermore, the state has not put into place adequate services for the aging, say advocates. The elderly — long deeply respected and honored in Indian culture — will be left to fend for themselves.
India’s population over 60 is expected to more than triple by 2050, and its 80-plus population is expected to quintuple, according to an article, “India’s Baby Boomers: Dividend or Disaster?” by David E. Bloom, a professor of economics and demography at Harvard University’s School of Public Health.
Activists and experts fear India is not in a position to handle so many old folks.
“There will be this huge mass of aging population,” said Rupa Chinai, a Mumbai-based journalist who has covered health and development issues for the past 25 years. “But we don’t have the services that are going to be needed by the graying population.”
India must be proactive and prepare for this growing population of elderly before it becomes a problem for the country, according to Bloom. “Enacting policies to meet the education and training needs of India’s youth can ease the process of caring for growing numbers of older Indians in the future,” he writes.
India’s rapid economic growth has set off a series of social and cultural changes that have deeply impacted the elderly and are likely to become more pronounced.
Indian values have long been tied to a particularly high degree of respect for the elderly. A common tradition in India has been the young touching the feet of the elderly as a sign of love and respect. The culture has also supported multi-generational living in which the sons, daughters-in-law and grandchildren all live with the parents under one roof. As the elderly have stopped working, the sons and daughters-in-law have traditionally taken care of them while living in the same house.
Modern, urban India is seeing more and more of these so-called joint families break apart. Adult children are marrying and moving into their own high-rise apartments that only fit their nuclear family. Others are heading off to the United States or Europe to study or find work and settling down there.
GlobalPost in Dhaka: Photos of parents in Bangladesh forced to live out their old age alone
Rural India has not been spared from this change either. While the majority still live in joint families, more and more of the younger generation is heading to cities to find jobs and start life anew — without their parents or grandparents.
Fewer than 40 percent of Indians now live in joint families.
“Children are moving to cities for their job opportunities and leaving the elderly behind,” said Sheilu Sreenivasan, founder and president of Dignity Foundation, a Mumbai-based organization working for the rights of senior citizens. “For the first time senior citizens have to fend for themselves.”
The breakdown of joint families has had a profound impact on those who spent their lives expecting to grow old with their children, said Sarah Lamb, a professor of anthropology at Brandeis University and author of “Aging and the Indian Diaspora: Cosmopolitan Families in India and Abroad (2009).”
“The older generation grew up thinking it was normal to stay living in a multi-generational family your whole life,” she said.
This has caused a range of reactions, Lamb said, with some feeling a slight sense of liberation but many feeling neglected and abandoned by their families.
This is also problematic because India’s elderly typically do not have their own source of income and rely on their families or to a lesser extent the government for support, Bloom writes.
A report by HelpAge India, a senior citizens rights group, found that nearly 50 percent of India’s elderly are financially dependent on others.
For an idea of what challenges India will face as it grapples with this expanding pool of elderly, just look at the current population.
With almost no support from the government, the elderly now struggle to afford health care, housing and daily expenses, say aging activists.
“The elderly need food; they need pensions; they need healthcare — all of which is missing,” said Mathew Cherian, the head of HelpAge India. “We are completely at a loss, and this problem is only going to grow.”
Health journalist Chinai said she has had to put her life on hold to take care of her aging parents because no other support is available.
But as the cost of living rises in India, most families need multiple sources of income.
HelpAge India released a report in June showing that India’s elderly increasingly face neglect and abuse from their sons and daughters-in-law who now view them as a burden.
As households get smaller and more congested, the stress in families has increased, and the elderly have had to bear the brunt of the anger, according to HelpAge India. About 35 percent of India’s elderly have experienced emotional or economic abuse, the report states.
The elderly who have worked in the formal sector receive pensions, but more than 90 percent of India’s population, like Beg the rickshaw driver, still work outside the formal sector.
The government has a pension program for the very poor, called the Indira Gandhi National Old Age Pension Scheme, which provides 200 rupees ($4.50) a month to the elderly who live below the poverty line. The Indian cabinet recently approved a bill to lower the program’s eligibility age from 65 to 60 and give 500 rupees a month to those above the age of 80.
About 16.9 million people now receive this pension, and the lowering of the age requirement will make an additional 7.2 million people eligible, according to a report in the Hindu. But activists say this is not enough.
Of the 80 million elderly, 51 million are poor and need government support, Cherian said. HelpAge India argues the number of people who receive government pensions must be expanded, and the amount of money should be increased to 1,000 rupees a month.
In addition to social security benefits for the poor, aging activists say the elderly need assistance receiving and paying for healthcare.
The majority of hospitals in India do not have geriatric wards or special services for the elderly.
Beg said he cannot go to a government hospital because he would have to stand in line with the general population for four to five hours before seeing a doctor.
Once he saw the doctor, he or she would be so overwhelmed with patients that Beg would not get more than a few minutes to discuss his ailments. If he needed medication, he would likely be given a prescription and have to buy it elsewhere because the public hospitals run out of — or allegedly sell to the black market — their stock.
He also would have a difficult time affording treatment. There are no subsidies for prescriptions or surgeries for the elderly, says HelpAge India.
The government announced a National Policy on Older Persons in 1999, but aging activists say it has not been implemented effectively.
Until now, India’s health care system has been focused on other needs, like providing maternal and child health and battling communicable diseases such as HIV/AIDS.
Thanks to a growing demand from civil society and a vocal movement of aging activists, the government is now showing an effort to address the needs of the elderly as well, according to A. B. Dey, head of geriatric services at the All India Institute of Medical Sciences (AIIMS) in New Delhi.
The government has plans to create two national institutes of the aging as well as state geriatric programs that will train medical professionals in geriatric services. “The focus is in creating that premier layer of professionals who have real insight into the issue of old age in a developing country,” Dey said.
The problem, he says, has been bureaucracy. “They are all in the pipeline, but our pipes are so long they don’t come in time,” he said. “But we are moving.”
In the meantime, the non-profit sector has stepped in and provides some health, housing and advocacy services for this population.
At the HelpAge India mobile van, for example, Beg waits in line for maybe 20 minutes, pays 10 rupees ($0.23) and receives medical advice and free medication for his high blood pressure. The organization treats 1.25 million elderly a year across the country with these vans, Cherian said.
The private sector has capitalized on the breakdown of joint families by building retirement communities for India’s rising middle class. GlobalPost’s Jason Overdorf writes that real estate developments for older people are mushrooming in urban areas.
However, these homes are expensive and out of reach for most Indians.
Furthermore, India’s long culture of joint families and deeply rooted sense of respect for the elderly has created a situation where there is a strong stigma against putting one’s parents in an old age home, Brandeis professor Lamb said.
When researching the retirement communities, many people told Lamb that the homes were not part of Indian culture because “Indians care for their elders.” The idea of a retirement home, Lamb said, “is still considered quite radically new and not normal.”
To address these concerns, some companies have tried to infuse Indian values by creating services that mimic the tradition of a family member caring for the older adult, she said. An Indian living abroad can hire the company Your Man in India, for example, to run errands for an older parent. Other groups will send someone to have tea with an elderly parent in a retirement home.
As India grapples with how to respond to its expanding aging population, it must not only make practical decisions on health-care costs and pension plans, but also decide how this will impact its national identity.
Will Indians’ long-held respect for the elderly continue in the face of modernization and Westernization?
“Some people are excited that India is progressing materially but do want to hold onto core Indian spiritual and family values. There is sort of that [identity] crisis going on” as people are asking, “how do we do this?” Lamb said.
Hanna Ingber Win on Twitter: Follow @Hanna_India