Pakistan: No country for old people
No country for old people
Having spent years toiling in building the future of their country and their children, senior citizens find themselves on the margins of society
In the sweltering heat of Karachi, a bearded Abdul Qayyum perspires profusely as he waits his turn in a queue outside a bank to pay a utility bill. With the line moving along very slowly, beads of sweat trickle down his forehead and onto his shalwar kameez. Despite the wrinkles on his face now gleaming with sweat, nobody from inside the air-conditioned offices came to Qayyum’s rescue.
This is not a one-off incident.
Similar scenes are also witnessed at the National Database and Registration Authority (Nadra) offices or the passport offices, where officials rarely go the extra mile for senior citizens, treating them with the same standards as they do other, younger and healthier citizens.
In Pakistan, the norm is to have senior citizens visit these offices in person regardless of their health or physical condition. No senior citizen counters exist at these offices, or if they do they are non-operational. This is far from the values taught in schools: to respect, to help and to facilitate senior citizens. “When we were young, we read about how a sophisticated society acts and treats its senior citizens, but now, I realise that life is quite different from what I read in my school books,” says Mrs Nasim Dilawar, a senior citizen from Lahore.
Mrs Dilawar too is enraged at the treatment meted out at governmental and other offices. “It is quite disturbing, because to see how such government organisations treat senior citizens. It is obvious from their attitude that they think they are doing us a big favour,” she says. “Officers should be trained to be patient while dealing with people our age. Their attitude shows that either standard operating procedures don’t state how to deal with senior citizens or, if they do, they are not taught, followed and monitored in practical life.”
Dr Mohammad Tariq Bucha, Vice President of Senior Citizens Foundation of Pakistan (SCFP), DHA and Cantt Chapter, Lahore, believes that Nadra, passport offices and banks do have senior citizen counters but that overlooking senior citizens has become ingrained in the officials’ attitude. He suggests that the government must implement laws that benefit the elderly and provide them with amenities.
“In 2011, the SCFP formulated a draft bill that entailed providing facilities to the senior citizens; the bill is at present with the government of Punjab. However, the only law present for senior citizens is the one that people themselves follow by helping the elderly in the name of humanity,” argues Dr Bucha, adding that the government has been neglecting the needs of senior citizens and hasn’t undertaken substantial efforts to redress the situation.
Dr Bucha believes that making designated counters for senior citizens in pension offices and other organisations will not help unless a cultural change is instituted in favour of senior citizens by the government. “Abroad, officials consider it their duty to serve the senior citizens while here it is considered a compulsion. This is the difference between Pakistan and other countries,” says Dr Bucha.
The SCFP representative believes that globally, it is the government’s regulations and policies that provide benefits and services to senior citizens — a trend that is unfortunately absent in Pakistan. “Our mindset is such that it considers senior citizens as redundant. People have become indifferent towards the senior citizens and generally do not care about them and their needs,” argues Dr Bucha.
There is of course much to improve upon.
Javed Jaffery, a senior citizen from Karachi, points to a lack of infrastructural facilities for senior citizens. “People who use a wheelchair face difficulties in commuting. Moreover, builders should keep in mind the difficulties that physically challenged or senior citizens may face and incorporate them in their infrastructure’s blueprint.”
Growing old can be hard to come to terms with. One has to deal with lost friends, physical frailty, and a rapidly changing society that pays only lip service to the idea of taking care of and respecting the elderly.
Mrs Dilawar also believes that the media must highlight the issues that senior citizens are facing. “I have seen proper ramps and lift facilities in offices, wedding halls and shopping malls, etc. but there is much more to be done. We are quite underdeveloped if compared with other countries,” says Mrs Dilawar.
When asked about notions of “respect” accorded by Pakistani society to senior citizens, Dr Bucha argues that while there is some level of respect, rise in materialistic values has taken away the real reverence that our society once had for the elderly.
Dr Bucha believes that the government must at least ensure that everyone working in government organisations facilitates senior citizens in carrying out their tasks. “The media too isn’t playing its due part in stressing upon the need to take care of senior citizens. Instead of placing small news items in print and running a news ticker on television, the media should create awareness regarding what senior citizens actually need. This social issue requires immediate attention as it is only putting the elders of the society under stress.”
Amidst the humdrum of the everyday, senior citizens remain adamant that change will only come about if and when the government takes a proactive step forward. “Senior citizens have years of experience as they have gone through thick and thin in their lives. They must be given the respect they deserve,” says Dr Bucha.
Another kind of care
by Sajida Ali
Dr Muhammad Junaid Patel is Associate Professor at the Department of Internal Medicine and work in the Geriatrics Programme at AKUH. Here he talks to Dawn about about the special healthcare needs of the elderly.
How are geriatricians different from general physicians and other specialists?
Geriatricians stress on primary care since prevention is not just better than cure, it is in fact the only cure. They focus on preventing the occurrence of health complications to avoid the need for treatment.
Since the elderly often suffer from multiple problems, if they go to various specialists like cardiologists, endocrinologists and gastroenterologists and each one of them prescribes a separate set of medications, the resulting polypharmacy (use of multiple medications by a patient) can cause adverse complications, side effects and drug reactions. Geriatricians adopt a holistic approach and where possible they prescribe one medicine to solve multiple issues, such as the same medicine to treat both high blood pressure and prostrate.
They try to avoid medication and instead suggest healthy lifestyle modifications. For sleep disorders and insomnia, geriatricians suggest better sleep hygiene instead of prescribing sleeping pills which could result in a fall caused by disorientation. Incontinence, for example, can be controlled with decreased fluid intake and exercising pelvic floor muscles.
Geriatricians also think about palliative care. They counsel the elderly patients about their treatment and whether future care will lead to a prolonged productive life or merely prolonged suffering. In cases of advanced or end-stage illness, such as kidney, liver or lung malfunction, or cancer or advanced dementia, geriatricians give their patients the choice to receive comfort care for a pain-free remainder of life instead of aggressive care such as shock treatment and chemotherapy, after explaining the implications of all available options.
Do we have viable geriatric care in Pakistan?
Though people 65 years of age and above do require geriatric care, the age at which patients may need a geriatrician is determined by their individual needs.
As life expectancy in Pakistan is increasing steadily with better healthcare and with the growing awareness of the importance of prevention, more and more people will need geriatric care in the future. We have the example of such programmes in developed countries and we can learn from them, but we have to modify and adapt the programmes according to our socio-cultural norms and religious practices, as their models of family and individual dynamics are different from ours.
Elderly patients need to focus on staying fit by avoiding habits such as a sedentary lifestyle, drinking, smoking and unhealthy eating. If they wait to fall ill and then seek care it is a big drain on their own and their families’ time and resources. It is never too late to start primary care for elderly patients.
What are the most common health concerns faced by elderly?
The elderly mostly suffer from the same ailments as those affecting younger people but the effects are remarkably different. In senior citizens, organs such as eyes, ears, heart, kidneys, lungs, muscle mass and bone density, and their functioning, become weaker and more vulnerable in old age. This often results in comorbids (a disease or ailment existing simultaneously with and usually independently of another medical condition), which may include malignancies, non-cancerous enlargement of the prostate gland (benign prostatic hypertrophy), hypertension, diabetes, high blood pressure, osteoporosis, dementia and stroke. Healing becomes slower and reaction to medicines and treatment becomes riskier.
The presentation of illnesses also changes. Hearing or vision impairment in elderly patients may present with depression. The occurrence of urinary tract infection (UTI) may present itself as confusion and, as a result, the patient and family members may not be able to identify the problem.
Besides health concerns, elderly patients also face psychosocial concerns. They are distressed about losing their status and career. They are anxious about the onset of limitations brought on by poor co-ordination and slow movement. Their dependence increases and physical and mental health decreases. Conditions like incontinence cause embarrassment. They may not be able to take care of their spouse like before; and if they have lost their partner, they may be feeling lonely.
Problems also arise when some side effects of conditions such as loss of bladder control, being taboo subjects, are not discussed with the care-giver (especially if the care-giver is of the opposite gender) and so not dealt with properly.
All these factors combine to create a state of acute depression among the elderly, due to which suicide rates are on the rise. Some phenomena peculiar to Pakistan — terrorism, poverty, political instability, corruption, lack of resources and the high rate of brain drain where children leave their country and parents behind for a brighter future — are also a cause of acute depression in the elderly in Pakistan.
How can the life of elderly patients be improved?
Elderly patients need to focus on staying fit by avoiding habits such as a sedentary lifestyle, drinking, smoking and unhealthy eating. If they wait to fall ill and then seek care it is a big drain on their own and their families’ time and resources. It is never too late to start primary care for elderly patients.
Regular checkups can help detect and possibly prevent conditions like osteoporosis, diabetes and any deficiencies they may have.
Elderly patients should follow medical advice diligently and co-operate with their caregivers. They need to understand that if they refuse to exercise, eat the right food or take medicines on time they will add to their and their family’s problems.
Depression can be avoided by maintaining a positive attitude and being thankful for and enjoying all the spare time they have. Counselling for depression can be sought if needed.
It would help greatly if the elderly patients accept and adapt to their limitations; and modify their lifestyle, such as using a cane or wheelchair for mobility, installing slip-proof flooring and purchasing easy to use gadgets and equipment.
What role does the family play in taking care of the elderly?
The family support that still exists, to a large extent, in Pakistan goes to the advantage of the elderly as they are taken care of by their family members.
Family members who have to shoulder the responsibility of care-giving can make their task easier by educating themselves about the patient’s specific needs including psycho-sociological, dietary, physical, mental and emotional requirements. Awareness about a condition and its related issues can help them understand the patient’s behaviour, such as aggression, and seeking professional counselling on how to deal with these issues can make care-giving easier.
The use of walking and hearing aids, and home nursing for assisting with physiotherapy, medication or hygiene, facilitate both the patient and the care-giver.
A happy patient is a healthy patient. Counselling and reassuring them, preparing them for what lies ahead, instilling positivity, showing love and care and paying attention to them when they talk, even if it is long winding, can raise their spirits. Other morale boosters include involving them in projects, arranging physical, outdoor and social activities with mixed age groups, and letting them know they will always be important and needed.
Home is where the heart isn't
Is it just following Western footsteps or do we really need a place where the elderly can be taken care of
A banker by profession, Rukhsana lives less than three miles from her ageing parents’ home and drops by almost every day to see if they need anything, from medical care or just random errands. Many times she has had to rush her parents to the emergency room on receiving SOS calls in the middle of the night. There have been times she has reached her parents’ home to find her mother crying with pain due to her advanced osteoporosis or her father suffering from a concussion due to a fall. Rukhsana shudders at the thought of what could have happened if she wasn’t around. Try as she might, she simply cannot hope to be there every time they need her.
“If only there was some kind of specialised and focused care around where I could place my parents in, I would be so relieved,” she says. Yet the very thought of putting her parents into an old people’s home is distressing to her.
Nadeem H was offered a wonderful job in Dubai which he reluctantly accepted. “My elder brothers migrated to the US after receiving lucrative offers,” he says. “After my father’s death, I decided to stay back because I couldn’t leave my widowed mother alone. She was the one who forced me to take up the opportunity, but she didn’t want to accompany me to Dubai. A former teacher, she said she wanted to spend her retirement years in her apartment in Pakistan. I come every other weekend to see her but it worries me no end as to what might happen to her while I am not around,” he says.
But his mother will not even hear about the possibility of moving into a home for the elderly, “I have a lot of family that I am happy interacting with when Nadeem is not around. Besides, if I decide to live in an old people’s home, people will think that my son has dumped me there,” she says.
Then there’s Saeed, who considered leaving his fairly lucrative World Bank job and returning to Pakistan because he was concerned about his parents. “My father always used to tell me not to worry about him and Amma because they had plenty of help around but I still wasn’t quite convinced,” he says. His father passed away three years after his return, and Saeed stayed on to take care of his mother. He’s back to working for the World Bank, but is now based in Karachi and is more than happy that he can keep an eye on his aged mother.
And so is his mother: “I am very happy that my son returned. Living in an old people’s home is out of the question for me,” she adds.These stories may not justify the need of an old people’s home or the idea of parents living in old people’s homes when children are alive or around, but Irshad Mowjee, a stakeholder of the Ida Rieu Mowjee Elderly Home (IMEH) project, believes that many children today are unable to cater to the special needs of elders.
According to informal surveys across South Asia, placing parents in old peoples’ homes is considered a matter of disgrace for the children. “The question of placing parents in old homes is quite knotty,” says Air Commodore Shabbir, a dedicated social worker.
“The parents need a great deal of care, affection and help in old age but children are unable to provide for them accordingly as they live in a world where you have to run a constant rat race.”
Mowjee insists that living in old homes should not mean that children have dumped their parents there; sometimes it is in the best interest of the elderly.
“I know an elderly person who lives on the second floor of a flat (with his son) which has no lift. For years he has not been able to go out. In case of an emergency, he has to be carried down causing discomfort to him as well as to his attendants. However, they refuse to put him in a home for the elderly.”
Despite cultural norms, according to a study supported by the UN and carried out by HelpAge International, an NGO that works globally for the rights of old people:
“Pakistan is ranked among the three worst countries to grow old in, as it is ill prepared to deal with old people. It is ranked 89 out of 91 countries included in the study.”
The elderly also do not have any age-specific rights or a government sponsored social security system that they can benefit from.
“There are no old-age specific facilities for old people,” says Mushtaq Ahmed who retired from a reputed bank. “More than letting parents live in old homes, most children want their parents to be involved in some fulfilling activity which is very important for their wellbeing.”
With the joint family system being replaced by nuclear families, many parents find it difficult to sustain themselves financially on their own.
“There certainly is a need for the elderly to be looked after at a home which has a professional approach,” says Mowjee. At IMEH, he says, “our policy is (to ask whether) by staying at the Elderly Home the residents’ life will be better or worse off.
If the answer is that it will be better, then there is a need for this sort of facility. We feel that there are many cases where the children are abroad and there is no one here to look after the parents or where the spouse has died and there are no children; in such cases a ‘home’ seems the perfect answer.”
How should the stigma attached to old people's home be addressed?
“We need to realise that we are a giving nation. You will be surprised to find the number of volunteers who are willing to render their services and give time to this noble cause. Many times the children cannot provide due to financial or time constraints; they are looking after their own kids or are busy with heavy work schedules. Life is very stressful and is becoming more so with all the law and order issues. There are a lot of pressures on young people.”
“Thus ageing parents’ care is put on the back burner, not deliberately but because of different constraints. If the children are made to see the logic of it, then I am sure they would see the reason but for this awareness is very important. They should see for themselves how the ‘home’ is being run and ask: Will my parent be better off there rather than at their house. If the answer is in the affirmative then there is no issue,” he says.
Names have been changed to protect identities
New tricks for old sparks
Eighty-year-old retired principal Mrs Sabir loves playing letter scramble, the iconic word puzzle game. But without a partner to play with, Mrs Sabir has found a new way to satiate her desire: switch her computer on, go online, and play with potentially hundreds of people.
“Technology has really transformed our world into a global village. My generation could never have conceived of using computers for such purposes,” Mrs Sabir exclaims.
Mrs Sabir finds great utility in being tech-savvy. Herself an active user of Facebook and Twitter, she regularly uses the two social networking sites to connect with her children, family, colleagues and students. “It’s amazing how I’ve reconnected with a number of my colleagues and students after such a long time through social media. I love posting comments and liking my children’s pictures, playing scrambleas well as updating my status on Facebook, especially when I’m traveling,” she says.
She isn’t the only tech-savvy senior out there; the use of social media is becoming more and more popular among senior citizens, as it facilitates connecting with family and friends and exploring new options for entertainment and hobbies. Then there is access to information about health topics, and managing everyday activities, such as banking transactions and shopping.
“I’ve subscribed to a wide range of medical e-journals and browse different sites to learn about innovation and advancements in the medical field. I often Skype with local and foreign doctors and feel connected with my fraternity. Technology is a treasure trove of knowledge for younger generations!” exclaims Dr Ahmed Khalil, 75, who is an ardent internet user, and finds it useful for staying abreast with the latest developments in medicine.
Many senior citizens argue that they keenly observe young people use the internet and social media, and wished they could use it too, but only if they had free internet access and reasonable training. “My children use social media via their smart phones and I’m very eager to learn too, but only with free internet access at home,” says Nadeem Ashraf, another senior citizen.
Though Mrs Sabir, Khalil and Ashraf are examples of senior citizens who have embraced technology, there are still a sizable number who are unfamiliar with, or afraid of, technology. A survey carried out by the Pew Research Global Attitude Project, US, reports that only two per cent of senior Pakistani citizens have personal internet access and just over one per cent have attained an online presence in the last two years. Such curtailed access is due to various impediments, including carrying unfavorable opinions about technology, and strongly believing digital communication is “not for them”.
“These shimmering gadgets have never been a part of my life because I will not derive any benefit from them. They are irrelevant and unsafe. Unlike youngsters, I’ve never relied on a computer for information or entertainment. I’d rather read an encyclopedia for knowledge and visit my bank to transfer capital instead of depending on machines,” argues 68-year-old Ashraf Ali.
Another senior citizen who actively resists digital services and wants to perform her daily tasks manually is Mrs Ahmed, grandmother to three. She doesn’t use technology for social interactions because she feels it’s difficult to operate it at her age. “Mobiles, Internet and social media are the inventions of the new millennia for socialisation. They are quite complicated to learn and I keep forgetting the functions,” she explains.
Sociologists believe that little motivation, an inadequate understanding of what technology offers, insufficient training and support and inappropriate marketing and designing of technical products create significant barriers to older peoples’ use of technology.
“Many seniors feel technology isn’t for them; that they aren’t equipped to deal with it and worry they might cause damage by pressing the wrong button,” explains Dr Asma Baloch, assistant professor at the Karachi School for Business and Leadership. “Many aging adults are oblivious of the benefits of technology and fear being tricked. Besides, marketers aim at promoting the gimmicky aspects of products and sites only, which don’t attract the older population. The dearth of reasonable tutors, training institutions and elder-friendly devices contribute greatly to their digital isolation.”
During interviews, a number of senior citizens also attributed their digital exclusion to their diverse economic and educational backgrounds, coupled with linguistic challenges. “Older adults buy their children expensive products instead of using those themselves. In many cases, this is because senior citizens feel that young people are more adept at using technology or communicating in Roman Urdu,” continues Dr Baloch. “Nevertheless, technology can play an important role in helping older people avoid social isolation, renew or develop new social contacts and actively engage with their communities,” he concludes.
As Mrs Sabir will tell you, all that the elderly need is proper training, advocacy and the resources to use digital products as efficiently as younger people. “Technology makes me feel connected, empowered and independent!” she says.
At the dusk of life
“Kia sab isi tarha chalay jain gay?” (Will everybody leave like this?) is all that Noor could say when he was informed of a friend’s death. He had just returned from the funeral of another old companion when he received the sad tidings. The death of two friends in just one day left him not just bereft, but also brought him face to face with his own mortality.
Sadly, what he experienced is commonplace among those of an advanced age. Slowly but surely, the landmarks of one’s childhood, youth and adult years disappear, and so do those one spent those years with. And there are other sorrows as well.
For those who have spent an active life; retirement and progressing age bring feelings of uselessness and despair. Those who have worked their entire lives now find it difficult to kill time since their lives previously revolved around their work schedules. Hamid, who was forced by his children to give up formal work at the age of 70 when he began to show signs of stress, finds it difficult to spend the day at home.
“How much can a person read or watch TV? The city situation makes it difficult to go out to meet people,” he complains. Not having much to do otherwise, he keeps himself busy by taking care of small chores around the house.
He looks forward to the days he has to pick his grandson from school. Though the child’s mother usually picks him up, when she is busy Hamid volunteers to go in her place. They don’t come back directly but instead take a little trip to get his grandson a small toy or a treat for lunch. Hamid is friendly with many of his grandchild’s friends and is thinking of taking up volunteering at the school if only such a programme existed.
The lack of activity or involvement is a major cause of depression among the elderly. With fewer responsibilities on their shoulders and not having tasks to do, they often begin to their lose purpose in life and begin to think that they are now useless and sometimes even a burden on the family and society.
Mrs Zahoor* has another problem. She has always taken pride at being a homemaker. “I never worked outside the home, and never regretted it.” Now with failing health she is not able to do all that she loved doing — cooking and taking care of everything around the house. However, she is not ready to give up. “If I don’t do this, what else would I do? Plus someone has to do it.” Perhaps she doesn’t want anyone else — her daughter and daughter-in-law, who are both working women — to take additional responsibilities or maybe she doesn’t want to let go of something that has defined her for so many years.
Mrs Zahoor is lucky that she has her children with her, though they do not need her attention as much as they did when they were young.
For many parents, a time comes when their children are no longer with them; some leave for greener pastures while others may consider a nuclear family as better suiting their lifestyle and hence move out, leaving the parents alone.
The parents may be well provided for and may have other people or domestic help caring for them and doing their chores, but the very thought that they are away from their children adds a feeling of loneliness to depression.
Some, if in good health, make themselves useful by volunteering for community service (where possible) or social welfare work.
However, sadly, the general perception social welfare is the domain of young, energetic people.
Now, it may be true that young people are more energetic and can run around to get things done but the experience and wisdom that the elderly possess is matchless, and they can guide the younger lot in meeting their goals.
Ahsan is one such senior member of the society who spends almost every evening with a couple of like-minded (and like-aged) people from his community. Presently, he is working on establishing a small computer centre and library around the nearby mosque.
Under his and his friends’ guidance, the youngsters from the neighbourhood are helping to get things organised. His plans have not materialised yet, but he feels a sense of achievement and contribution to the society besides having some time well spent. He says that interaction with people much younger has made him see what the younger generation thinks and what they want.
This is just one example. There are so many ways in which the elderly can make the most of the time on their hands and keep themselves busy. They can pick up hobbies and interests for which they didn’t have much time when they were professionally busy; they can read books (or write books, for that matter) or help in small routine chores around the house. The key is to keep oneself busy and useful. Don’t count the years that have passed; count the ways you can make the remaining ones matter.
40
