Paper presented at the 24th Annual Conference of the Caribbean Studies Association (CSA),Hotel "El Panama", Panama City, May 24-29, 1999.

Transcription

1 AGEING AND THE FAMILY: CONFRONTING THE CHALLENGE JOAN M. RAWLINS Ph.D. Lecturer Public Health and Primary Care Unit Faculty of Medical Sciences University of the West Indies Mount Hope, Trinidad, West Indies Paper presented at the 24th Annual Conference of the Caribbean Studies Association (CSA),Hotel "El Panama", Panama City, May 24-29, 1999.

2 ABSTRACT Ageing and the Familv :Confronting the Challenges This paper acknowledses that life expectancy has risen significantly in the Caribbean over the past four decades. it comments on data which suggest that despite the longevity of our citizens, indi\iduals. famil, and government have not come to a fill appreciation of the significance of this situation The social health and economic implications of this added life expectancy are noted as many and varied. This paper draws on data collected in Jamaica, Trinidad, Barbados and St. Kitts and concludes that families, communities, and governments need to work collaboratively to ensure reasonable livelihood and equity for the Caribbean's ageing population.

3 AGEING AND THE PAM1LY:CONFRONTING THE CHALLENGES BY Joan M. Rawlins Ph.D. ~ntroduction In the Caribbean, as in other developing and developed countries, men and women are living longer than ever before. Life expectancy in the region has changed dramatically since the 1940s and there are now many concerns and challenges with regard to older persons which cannot be ignored, as they had been in the past. The ageing population is now a visible minority of which family and society need to be mindful. Indeed at 6-12 % through the region this group is significant for a number of reasons, which will be discussed later. What exactly do I mean by ageing here? Ageing is a concept which has different meanings in different cultures and societies. For example a society with an average life expectancy of 80 years will perceive ageing quite differently from one in which the average life expectancy is, for example, 55 years. In the latter a man of fifty will be perceived as old and toward the end of his days whilst this would not be the case in the former society in which a fifty year old would still be relatively young. Thus we might say that the perception and the reality of ageing vary from society to society. For the purposes of this paper I shall make use of the United Nations conceptualization of ageing. The UN makes reference to the young old, that is, those who are 60-74; the old those who are and the very old, those who are 85 years and older. Additionally, the gerontologists, those professional, whose work keeps them totally occupied with the concerns, problems, conflicts and interactions involved in the ageing process make reference to the four ways of viewing ageing. They speak of biological, chronological, psychological and social ageing.

4 Caribbean populations have aged as result of the demographic transition. The demographic transition is that process which leads to an increased number and proportion of the elderly in the population. This increase is determined by a series of events, namely: (1) significant decline in mortality leading to an increase in population (2) fertility rate decline which leads to a decrease in the younger population and a trend towards an increased population of older age groups and (3) increased life expectancy To show the magnitude of the change in our ageing population over time, demographic data for the Caribbean is shown below (Table 1). le 1 Average Life Emectancv 1950, 1970 and Em 1997 Barbados Jamaica Trinidad Source: Harewood (1976) for 1950 and 1970 data and PAHO for 1997 data. Life expectancy has risen in the Caribbean from an average of 50 in the late 1940s to an average of 70 for men and 73 for women in most of the English-speaking Caribbean, with the "population of those over 65 years rising from around 4 to 10% over the period 1950 to 1990". (Lewis, 1996). We note the added life expectancy for women, thus many of the challenges will be gender related. Table 2 shows the changes which we can anticipate for the elderly as a percentage of the total population for three Caribbean countries.

5 P o w o n over age 60 years as a gercenlsae of total lected pert- for the years 2000 and Barbados Jamaica Trinidad Source: Projection data, PAHO, 1985 The population pyramids throughout the region now reflect a different reality from that which they did at the turn of the century ; the over sixties no longer represent a dot at the apex of the pyramid. Their numbers have increased, and as a group their specific concerns have to be addressed by family and society in much the same way as we might address the needs of the maternal and child health group or the under fives in the population, who represent an average of 11% of Trinidad's population (Patrick, 1995), with similar figures for other countries of the Caribbean. As we move into the new millennium, the increasing number of this group will present a number of challenges for the individual, the family and the society. For the individual, as an older person he/she is no longer a novelty and society does not feel the need to automatically treat such a person with the reverence and respect which was formerly the situation. Worse still society has allocated a number of negative stereotypes to older persons and their situation which makes life sometime more difficult for them. This combined with ageism, the prejudice against individuals only because of their age makes being older less than pleasant for some elderly.

6 The Challenges The challenges which confront the ageing population and their families vary according to the social factors which are relevant to the particular situation. The challenges will encompass issues such as loneliness, changes in family organization, reintegration of returned migrants, widowhood, health care and retirement. Economic issues such as the problems of financing one's self in old age, inadequate pensions and social security, homelessness and poverty are other challenges. Health issues such as long-term hospitalization, the high cost of health care and the need for efficient care-givers in the family and institutional settings will be of special concern for many older persons and their families. Society often makes the mistake in assuming that elderly persons form one homogenous group, whose concerns and needs are all the same. Research has shown, in the Caribbean (Eldemire, 1993: Rawlins, 1996 and Rawlins and Spencer, 1999) and elsewhere, (Bond and Coleman, 1990) that the elderly vary amongst themselves as individuals, in much the same way that people of a younger age group are different. Elderly person do not constitute one homogenous collective, thus their concerns and problems vary, consequently solutions have to be found based on the specifics of the situation. However when we speak of the very old, there might be greater similarities, as at that stage, older people might no longer be independent and might have to be assigned to specific care arrangements. The questions which beg to be asked though are: Are we as a society ready to cope with the concerns of our ageing population? What is being done to ensure that added life expectancy does not leave large numbers of people in a significantly more disadvantageous state than had been their situation earlier? Have the various sectors within the state been made aware of their ~esponsibilities

7 to this group and the group's expectations of them? I would say that prior to this year (1999) the UN- declared International Year of the Older Person, throughout the Caribbean the consensus was that enough was not been done to cater to the needs of older persons nor is sufficient preparation being made for those who will join the ranks shortly. Despite the "flurry of activities" this year, we need to highlight some of the concerns which face the elderly; concerns which are a challenge to themselves, their families, and the society, and attempt to determine, what is being done and what else needs to be done. Firstly we need to note that many of the minor challenges which the ageing population face occur within the family, and that with the correct intent and will to help, solutions might be found within the family. It might be instructive for us then to look at the family situation in which our ageing population finds themselves. Ageing and the Family Within the Caribbean the family takes numerous forms (Barrow, 1996). The structure, function and strength of the family vary and consequently influence the kind of life situation which the ageing person can expect to experience. Rawlins (1996) and Eldemire (1993) have identified the main family situations in which ageing persons are most likely to find themselves. The ageing married couple might be living on their own, in their own home, after their children have established their own homes. Older couples might also be living together in a common-law relationship. However, the older woman who has spent most of her youthful days in a common law relationship might now be without that male partner through divorce, separation or death; she might then be living on her own or with one of her children and the grandchildren.

8 occasionally the older woman has to take back into her household an errant husband from whom she has been separated for ten or fifteen years. Most often he is seriously ill when he returns. This can be extremely stressful for an older woman, who might not be in perfect health herself. Because this is the age in which women are most likely to be widowed, there will be widowed women living on their own or with an offspring, either in the offspring's home or in her own home. In my research in Jamaica (Rawlins,1996) ageing women who no longer lived in their own home were most likely to be in their daughter's home. In Trinidad they were likely to be found in their son's or daughters home (Rawlins and Spencer. 1999). Older persons, in the region, who live on their own (the minority situation) are more likely to be men. Ageing men and women, then will spend their days with married or unmarried relatives usually their children, and a small number will spend their final days in homes for the aged and nursing homes. Ageing persons whose children live in "troubled" family situations will find that such family members might not be able to provide for them when the need arises. Additionally they might find themselves the victim of physical and psychological abuse, in essence "elder abuse". In a Barbadian study, reported in Grell (1987), Hoyos noted that 32 percent of the elderly clients in his study lived alone. This was very different for Jamaica (Rawlins, 1996) where 16 percent of the respondents (females only) lived alone. How the older person spends his/her ageing years will vary with class, and will also vary perhaps for those and those over 70 years old, and will be related to the health status of the

9 individual. My study in Trinidad and Jamaica showed that ageing women preferred to live in their own home for as long as it was possible. Their decision to move out of their own home was at times related to their health status, and to their desire to reorganize their financial situation - to better provide for themselves in the event of very long life. Sometimes they sold their home, bought a smaller unit and invested the excess money. At other times their house was converted into smaller units to allow for rental of some part of the house as an income earner. Retirement planners throughout the Caribbean, suggest that if one needs to build a home in ones middle years one should build it in such a way that it might easily be converted into a two bedroom home and a two bedroom apartment. This makes it easier for the individual in their later years to provide retirement income for themselves by renting the house or the apartment as necessary. Individuals and family members need to face the challenges which confront the elderly squarely and sensibly, to ensure that a significant sector of our population is not any more disadvantaged in terms of the physical, social, emotional and spiritual than are other members of the population. Changing family situation One of the challenges which faces the elderly in our society relates to changing family patterns. By this I am referring to the fact that in many situations, family size is smaller, family members do not live together in large family groups as was the case with the extended families of the past. This means that there are fewer family members to cater to the needs of the ageing parents and other elderly members of the family. Additionally more women are in paid employment, which keeps them away from the home during the days and unavailable to provide care for elderly family members.

10 Migration Migration is an important feature of Caribbean reality and another social factor which presents challenges to family and society in relation to our ageing populations. Large numbers of our people move away to other countries. In so doing they reduce the pool of persons available to cater to the need of the elderly. Some provide financial assistance from abroad, which is useful to the elderly, but others leave children behind to be cared for by the elderly, often without making the necessary economic and social provisions. This was the case for the Jamaica study (Rawlins, 1996) and anecdotally is the case throughout the Caribbean. Returning residents, from the USA, UK and Canada, face many challenges as they attempt to reintegrate into the society. They often return at the point of retirement; sometimes with funds which they are prepared to invest. However some return as sick and very elderly and place additional burdens on the health care system and on relatives who are ill-equip to manage their situation. Finance Throughout our lives the more astute amongst us make plans to ensure that our aspirations have a chance of becoming reality. Unfortunately too many people make no meaningful plans for retirement and old age. The problem the elderly face on retirement is that the available income is not sufficient for their needs, and often they must meet health care cost not previously experienced. In a study entitled "Profile of the Elderly in Trinidad and Tobagow, the financing available to the elderly came from the following sources: continued employment (less than fifteen percent) and from five main types of pension. These pensions were the national insurance scheme, private retirement schemes, government retirement schemes, old age pension and public welfare.

11 In the Jamaica survey (Rawlins, 1996) the financing available to the participants in the study came from similar sources. Relatives were mentioned frequently as a source of income. However in both places the elderly reported that income available to them was inadequate to their needs. Working class women who stated that they had their children with a mind to their being insurance for the future (Rawlins, 1996), found that the children were unable to do for them what they had hoped. The issue of financing the elderly should be seen as a challenge in need of careful consideration. Social Security Throughout the Caribbean, there are a number of systems of Social Security. Individuals pay into the system during their years of employment, and have benefits paid back to them in pensions and other allowances in their post retirement years and as widow's benefits where indicated. What emerged in my research in Trinidad, St. Kitts and Jamaica was that recipients complained that the benefits were not adequate and were out of sync with the cost of living. In terms of pension and other benefits available, people of all class groups showed their disaffection. Working class persons were more adversely affected, as some might not have paid into the systems, or where they paid, this might have been on an irregular basis, which then influenced the benefits which were available to them. In terms of gender, women were affected negatively, as they received smaller pension and benefit in keeping with their lower life time salaries and the fact that some had moved in and out of the work force in relation to family building activities. An additional challenge which society faces in relation to social security is related to the reality that in the near future the proportion of the dependent population will be closer to the

12 proportion contributing to the scheme, creating a situation which is not in keeping with the underlying conceptualization of social security. Ideally social security envisions a large pool of persons paying into a scheme, which pays out to a small proportion of beneficiaries. The changes in the dependency ratio (i.e the ratio of those less than fourteen (14) years combined with those >65 years, to those of working age years) reflect some of the challenges for families. This ratio measures the number of dependents which the productive population must support. The ratio varies considerably for the region being 75 for Barbados and 100 for Haiti. The average for developed countries is approximately 64. Another ratio which is sometimes used is the parent support ratio. 'The parent support ratio (PSR), which relates the oldest old (80 and over) to their children/carers (age , is a rough indicator of the need for support of the frail elderly. As females are the main carers, PSR by females is often calculated ". Eldemire (1997:252). Employment We need to note that continued employment is a reality for some older persons, from choice because it is their desire and because they have skill which are required by their community, whilst others continue to work as a matter of survival. In the study (Rawlins, 1996) 37% of the women over age sixty were in paid employment and continued to provide financial assistance to their immediate and extended families. In Barker's, St Vincent study (1995), she reported that "Employment for this group was high", and that 8% of the elderly had returned to work after retirement. The study also reported that "corresponding income from pensions was low".p.21.

13 Health care, ageing and the family Yealth and health care are issues which assume critical proportion for the ageing and provide some of the greatest challenges which family and society will meet. Although to be aged does not automatically signal ill health, the older person will in time be in need of additional health care. Throughout the region the main causes of morbidity and mortality for older people are heart disease, malignant neoplasms, diabetes, strokes and accidents. Health care whether obtained from the public or private health sector is costly (Levitt, (1991). The health sector organised by government throughout the region tends to be over stretched; the elderly are rarely treated as a special group, and need to compete for health services along with the other age groups of the population. The private health sectors throughout the region vary in their ability to provide for the elderly. Middle class individuals with savings and health insurance fare better in this system. Those without health insurance and relatives to pay the required cost do less well. Anecdotally we are told that 30-40% of the occupants of the medical wards of the major public hospitals in Trinidad, are older persons. This would be the case for at least a similar percentage for other major hospitals in the region. For the very old, and the sick elderly who need to be institutionalized, there are state run as well as private nursing homes. These vary in terms of the services they offer and the material and human resources available to manage their service delivery. These homes are usually supervised by the Ministry of Heal.th or the Ministry of Social Development in the various countries, and their critics argue that most need to be more clo~~ly supervised. 4

14 The ideal though in terms of care for the elderly is that such care should take place within the family-home. This remains an ideal and will not always be possible given the particular and sometimes the peculiar situation of the individual's family life. In a Trinidadian study (Rawlins and Spencer, 1999) we explored the situation of the chronically ill older person and concluded thae the ones most likely to bear the burden of care were wives, daughters and daughters in law. In the case of the wives, who mos& often were older persons themselves, care giving, for more than a short period of time became a very special burden and a frustrating exercise. It is however not always possible to provide home-care for the family members with Alzheimer's disease and other chronic conditions. Many, including older women, who themselves, ironically, had provided care for various family members throughout their lives, find that when they are in need of care, there isrno family member to help. The usual situation being, that their husbands had predeceased them and their children had migraaed- (Rawlins, 1996). Conclusion With the increased longevity of our Caribbean people, the facerof the Caribbean has changed, and of necessity the relationship between family and government needs to change with regard to the older members of society. It is only natural that these demographic changes should bring with them new challenges. The challenges which these larger numbers present, run the gamut from social to ecommie to health. Some of the challenges will be more easily attacked a d overcome than others, but we would hope that none will be %rul$ insurmountable.

15 It would seem, that what is required to meaningfully meet these challenges is foresight. Family members and society need to recognise early that some challenges are inevitable, and that a plan will be necessary to do what will be required. There will also be need to identify and make ready the resources which will be needed to effect the plan. This should be a team effort by the individual, the family, NGOts and the government. A team effort will ensure that our ageing population will more likely enjoy a reasonably comfortable life-style in their evening years. The United Nations in declaring 1999, the Year of the Older Person, asked that countries adopt their (18) principles which they had laid down in 1991, to guide countries towards a better life for older persons. The eighteen principles are organised in five clusters, viz. Independence, participation, care, self fulfilment and dignity. The independence principles states, " the older person needs access to the basic services and care, opportunities to work to make an income, ability to influence the pace of withdrawal from the labour force, access to education and training opportunities, safe living environments and support to reside at home for as long as possible. As family and society prepare for a world in which there are larger numbers of older people, social security programmes will have to be reorganised and rethought in order to cater to a larger elderly dependent population. In the broader society, it would be good to take on board the UN principles as we seek to ensure continued employment for those who need to, or want to work. Time-sharing in waged-work might have to be introduced more widely in order not to foster conflict between older and younger members of the work force.

16 themselves 'ageing", as no one knows better what the 'the challenges of ageing" are, than those who themselves must deal with these challenges first hand.

17 REFERENCES A Profilenf t h e TrTrlnldad (1989) Technical Paper No.22. PAHO, Washington D.C. Bond, M and P. Coleman (eds.) (1990) In Society. Sage publications, London... Braithwaite, Farley (1990) The Elderly in Barbados. W e t h of P W 24:3. Conceptual Framework of a programme for the preparation and observance of the International Year of the Older Person in UN Department for policy coordination and Sustainable Development (1995). Digest of Selection of Demographic and Social Indicators ( ECLAC/CDCC, Demography Unit. Port of Spain, Trinidad. Eldemire, D. (1993) "An Epidemiological Survey of the Elderly in Jamaican. Ph. D. Thesis. University of the West Indies, Jamaica. Eldemire, D.(1997) "Health of the Elderlyn. In Health Conditions in the Caribbean. Pan American Health Organization pp. ( ). Harewood, Jack (1976) g c Workbook. Institute of Social and Economic Studies (ISER) and the CSO, Trinidad... Bealth Comhtlons in the AmerJcas - Raslc Indicators (1990) Vol.1 PAHO/WHO, Washington, D.C. c & e ~ - (1996) Vol.1 PAHO/WHO, Washington, D.C. Lewis, Merle (1995) "The Caribbean Health Situationf1. Unpublished Paper. Caribbean Epidemiology Centre (CAREC), Port of Spain. Trinidad. Patrick, Angela (1995) nspotlight on Health (Trinidad and Tobago)". Document prepared for the North West Regional Health Authority, Trinidad. Rawlins, Joan (1989) *Widowhood: The Social and Economic Consequences in the Caribbeanu, In Mid-life and Older Women in Latin America and the Caribbean, a joint publipation of Pan American Health Organization and the Amrican Association for Retired Persons (AARP), Washington D.C.

18 Rawlins, Joan (1994) "Gender, Ageing and the Family in the Caribbean. Lecture presented at the invitation of HelpAge International and the Centre for Gender and Development Studies, UWI, Cave Hill, Barbados. Rawlins, Joan (1996) nwomen from Midlife: Coping in Jamaica- A Study of Power in the Lives of Women Aged 50-74" Ph.D. Thesh, Institute of Social Studies, The Hague, The Netherlands. Rawlins, Joan (1996) "Health and the Midlife and Older Woman in the Caribbeantt. ectlves, Dec pp Rawlins, Joan (1999) "Confronting the Challenges of Ageingw. So~al W w. March,1999. Vol.xvii:1( ). Rawlins, Joan and Michele Spencer (1999) "The Unrelenting Burden of Care: The Situation of Care-givers of the Chronically I11 Elderly in Trinidad. Paper prepared for the, Caribbean Health Research Council (CHRC/CCMRC) conference; Bafbados, April United Nations Department for Policy Coordination and Sustainable Development(l995) Conceptual Framework of a programme for the preparation and observance of the International Year of the Older Person in 1999.