“It was really painful and hurt a lot,” says senior citizen Mr Ahmad* as he recalls how a series of disputes led to his son asking him to leave the home. “In our family such things have never happened in the last five generations.”
Mr Ahmad is currently living at a facility for the elderly in Karachi that is run by a faith-based charity. Such shelter facilities, common in the West, were unheard of a generation ago in Pakistan since the joint family system, in which children and their families live with their parents after marriage, continued to be a norm.
But as family dynamics change, there are many more senior citizens like Mr Ahmad spending their later years away from their sons and daughters in old age homes and shelters, says Laila Akber Cassum, a senior instructor at AKU’s School of Nursing and Midwifery, who conducted a study of the residents of two such institutions in Karachi.
Such facilities are becoming increasingly common in the city with non-governmental organisations, faith-based institutions and even those looking to create a second income establishing such facilities for senior citizens.
In this interview, she highlights the drivers of this emerging trend, explores its implications for the health of older people and explains the steps the provincial government and other stakeholders need to take to protect one of the most vulnerable groups within our society.
What were the most striking findings from your study?
I was surprised to hear the negative language used to describe older people. Senior citizens had mentioned being called ‘useless’, ‘troublesome’ and ‘difficult’ by their own families. This is especially tragic as companionship was the elderly’s greatest need and feelings of helplessness were common.
For many of the interviewees in the study, living in an old age home is a desperate last resort. This point is supported by other research studies. As far back as 2013, research studies have found that older people, admitted to two private hospitals in Karachi, were aware of such homes and shelters but just 7 per cent of the 477 respondents said they would be comfortable living there.
Like Mr Ahmed, other senior citizens had been forced to move because their married children did not want to live with them. However, people without family or those suffering from chronic diseases felt that a senior citizen home was the best option for them.
Why is there a move towards establishing shelter homes?
We have a growing geriatric population and there is definitely a need for facilities that can provide them with a range of extended services for housing, care and support.
The United Nations’s Department of Economic and Social Affairs estimates that Pakistan’s population of those over 60 will double by 2050. This means that one in seven of our citizens, or 12.9 per cent of our population, will be over the age of 60 by 2050.
The government also recognises the need for facilities for older people and the Sindh Senior Citizens Welfare Act of 2016 calls for the establishment of at least one old facility for senior citizens in each district of the province.
What’s concerning is that only a minority of these homes have been registered with the government. The prevailing practice is that anyone who can rent a house and hire a few maids can set up a shelter. This is worrying as the majority of our geriatric population needs trained caregivers and nurses.
Administrators of these facilities must also be sensitive to the special healthcare requirements of those who are bed-ridden, have chronic diseases or need assistance to complete daily tasks.
What are the key trends that lead to older people living in such homes?
There were a few prominent themes such as the impact of economic pressures and a poor family environment.
A number of interviewees shared that their child viewed them as being an economic burden. Financial challenges led to their children considering emigration to enhance their own prospects and to women joining the workplace. Both these decisions have meant that there are fewer people around to take care of the elderly. These changes have also resulted in senior citizens being viewed as an inconvenience and a strain on the household’s arrangements.
For example, one participant in the study recalled being told to find work and earn for the family on a number of occasions despite his old age. Another spoke of feeling helpless as he had become paralysed in an accident and could no longer work. Both are now living in shelter homes.
The second reason is a hostile family environment. The respondents’ male children often found themselves torn between the demands of their wife and the family. A number of interviewees noted that their son’s wife did not consider them to be family and forced them to leave the home. They also spoke about a lack of compassion from their daughter-in-law, which occasionally resulted in threatening behavior.
One participant recalled how he was devastated by his son’s death and became homeless soon after since his daughter-in-law refused to let him continue to live in the same home. Cultural factors were also a consideration for the parents of daughters as it wasn’t socially acceptable for them to live in their son-in-law’s house.
While some participants chose to reside in shelter homes instead of living somewhere without love, care, and respect. In other cases, the elderly were forced out of their own homes by family.
How did this affect the health and wellbeing of the elderly and how did they cope with them?
A number of participants spoke about loneliness. It was particularly pronounced for those whose spouses had passed away or who were ill. One interviewee shared how her daughter was a huge support for her but the responsibilities she had to take over after her marriage left her feeling alone. Similar feelings of loss and isolation resulted in many interviewees complaining of anxiety, depression and fear.
Another prominent emotion was helplessness as none of the participants in the study could work any longer and were anxious about how to fund their health and living expenses. The feeling of helplessness was particularly strong for those who had to go to hospital appointments alone.
Coming to coping mechanisms, many of the participants in the study cited prayer and religious observances as giving them inner peace. One interviewee even stated that her relationship with God helped ease her isolation. The majority of senior citizens shared that the practice of religious observances assisted them to manage stressors related to lack of money, loneliness, rejection, and lack of family support.
What can be done to improve the wellbeing of those in shelter homes?
People of all ages have the right to be treated with respect and dignity and this is mentioned prominently in goal 3 of the sustainable development goals.
Besides, more research on the mental wellbeing of our geriatric population, we also need the government to consider the elderly’s financial challenges. Those without a private or public pension are likely to fall into poverty at a time when they are particularly vulnerable since they lack a social support system. While the Sindh Senior Citizens Welfare Act of 2016 mentions the need for subsidised medical care and the establishment of old age homes by the government, we must ensure that these measures are implemented.
Policymakers must also consider setting up geriatric wards in public and private hospitals to offer an affordable option for those needing advanced care.
We also need greater regulation of such facilities for senior citizens. All old age homes and shelters must be registered with district social welfare officers and they must have caregivers and administrators who have the skills needed to care of the elderly.
Finally, more nursing schools and medical colleges must incorporate geriatric care into their curriculums. This will ensure that we have the skilled workforce to take care of our growing population of older people.
* Names have been changed to protect each individual’s identity and privacy.