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LEPROSY HOUSING PROJECT,
BETHANY COLONY, BAPATLA,
ANDHRA PRADESH, INDIA

Help the Aged

Urban Destitution/Health

AS/IND/122/EJ

OVERSEAS PROJECT INFORMATION
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Leprosy Housing Project, Bethany Colony,

Bapatla, Andhra Pradesh, India

Bethany Colony is a small settlement of leprosy affected families situated
on the outskirts of Bapatla in the state of Andhra Pradesh in Southern
India. The colony was first established in 1933, although it was not
until more recently that it began to take on its present shape of a
village, rather than merely a collection of huts.
Leprosy sufferers were originally drawn to the area by a large leprosy
hospital nearby. Once discharged from the hospital, they wre unable to
return to their own villages as they were ostracised because of their
disease and instead started their own settlement on derelict land next to
the main East Coast railway.
As time has gone by, homeless leprosy sufferers have continued to settle
at Bethany and some of the children of the -original settlers have grown up
as part of the colony. Although many of them do not suffer from leprosy
themselves, they are nevertheless bound by the stigma of the disease and
are unable to settle elsewhere as they are rejected by others.

Leprosy is a contagious disease, although the mode of transmission is not
decisively known. There are several kinds of leprosy which differ in
infectiousness and manifestation. Only a small proportion of people
infected with the leprosy bacilli actually gets the disease. However, for
those who do contract leprosy, regular drug therapy is essential to halt
the progress of the disease, render the patients non-contagious and to
ensure that they do not suffer the familiar progressive deformities.
In order to ensure that the leprosy patients at Bethany are able to
receive the treatment they require, a clinic has been established in the
heart of the community, making it easily accessible to the villagers.
Leprosy patients from the surrounding area also receive treatment at the
clinic. The clinic is managed by the villagers themselves, following
appropriate training in the various skills required. Records are carefully
kept and patients are monitored to ensure regular drug therapy. As there
are no quick, visible results from the drugs, health education is vital to
make certain that leprosy sufferers persevere with their treatment.
continued

1

One of the main problems facing the Bethany villagers is that they
encounter great difficulty in securing employment outside the colony
because of other people’s fear of leprosy,
Instead they have to beg in
order to gain some form of regular income, Groups of villagers travel to
the large towns on begging trips of several weeks, returning to Bethany
when circumstances allow. Prolonged absences from Bethany mean that those
suffering from leprosy may not be able to keep up the regular drug therapy
they require.

In order to try and provide the means of earning a living for the Bethany
villagers as many jobs as possible have been created within the village,
although not sufficient yet to put an end to begging for everyone. There
are limitations on the extent of labour which can be created for people
with leprosy. Manual disabilities resulting from leprosy cover a wide
spectrum and some jobs are therefore not suitable for leprosy patients.
In spite of this, however, all jobs at Bethany are done by the villagers
themselves. These include office work, weaving, shoemaking, animal care,
as well as work in the school, the kitchens and the village shops. Over
100 women are employed in the weaving workshops, working in shifts to make
beautiful bags which are in great demand.

Two Bethany men have recently been appointed as Managers to be trained in
the administration of the colony, and another colony member is to be
trained in social work later in the year.
Jacky Bonney, a British nurse who earlier worked at the nearby hospital,
is the Administrator of the Colony. She wrote in a recent letter to
Help the Aged, ’’The long-term vision of all Bethany’s work being handled
by Bethany people is beginning to take some physical form and I can hope
that a vision may become reality”.

A large number of the people living at Bethany are elderly and many of
them suffer from severe disabilities, such ■as deformed limbs and
blindness, caused by many years of untreated leprosy. They are unable to
travel to the towns to beg because of their disabilities. Those with no
family support are left destitute and have to rely on meals and free
medical aid which are supplied at Bethany for elderly and Infirm people.
A few of the elderly people perform simple tasks in return for the food
and a little pocket money.
The vast majority of the families in Bethany live in very flimsy
dwellings, many of which have encroached on land which belongs to the
railway. Some of the dwellings are situated just two or three metres from
the main Madras to Calcutta railway line. The area is regularly hit by
cyclones which sometimes destroy the Bethany dwellings, leaving the
villagers homeless.
Because of the stigma attached to leprosy, the
villagers have nowhere to seek refuge when their homes are destroyed.
In spite of their depressing situation, there is a great community spirit
amongst the Bethany villagers, who have made repeated attempts to improve
the standard of their housing.
In 1981, after protracted negotiation,
they obtained from the local authority the right to 13 acres of land on
which to build proper houses. However, the land they were given was
unsuitable for the contruction of housing as the ground was very uneven.

continued

2

The Bethany villagers could not afford to have the land levelled
themselves and therefore approached the local government for financial
support, which they managed to secure.

In addition to paying for the land to be levelled, the government also
agreed to contribute towards part of the cost of providing proper housing
for the Bethany villagers, although it has been left up to the villagers
themselves to find the remainder of the money required.
Since the traditional main source of income for the people of Bethany is
from begging and this provides mere subsistence, the villagers are unable
to donate even their time for the labour of building the new housing.
However each family is giving a small sum of money each month towards
labour costs, and those who are able to work are doing so at a lower rate
of pay than imported labour.

In order to make up the remainder of the money needed to pay for the
construction costs of over 300 houses, approaches have been made to
charitable organisations for financial support.
Locally-based charities were unable to help, but Help the Aged has
provided £14,754 and HelpAge India has also agreed to make a sizeable
contribution to the programme.
Although Bethany Colony comprises all age groups, the combination of the
grants from Help the Aged and HelpAge India make up 14% of the full amount
of money required. This is commensurate with the percentage of elderly
people who will benefit from the new housing at Bethany.

For further information, please contact:
Dee Sullivan
Press Officer

May 1987

3

4

DISASTICRS
aBfAHTTEE
Secretariat:
9 Grosvenor Crescent
London SW1X 7EJ

Tel: 01-235 5454
Telex: 918657 BRCS G
Fax: 01-245 6315

IfiHl wa W MMW
INFORMATION SHEET

Six British charities launched a major appeal on June 24 for
victims of war and drought in Mozambique. The Disasters
Emergency Committee is appealing for funds for programmes in
Mozambique and support for refugees from Mozambique in
neighbouring countries.

Background
A tragic combination of war and natural disaster has brought the
people of Mozambique to the edge of catastrophe. They are now
suffering homelessness and destitution on a massive scale. The
Mozambique Government estimates that, of a total population of 14
million, a third of the population is directly affected.
Parts of the north of the country can be reached only by air.
other districts remain inaccessible. The focus of rebel activity
shifts constantly and almost all the country's ten provinces have
been affected.
War has forced people to flee their land and homes leaving crops
untended. The conflict is regarded as part of a larger security
crisis throughout the southern African region. Civilians have
also been the object of attack, as have the country's essential
services, key economic installations and transport networks.
According to UN figures, 484 health posts have been destroyed
since 1982 and safe drinking water is available to only 13% of
the population.

Apart from displaced people within the country, over 460,000
people have crossed into neighbouring states in search of food
and safety.
Increasing numbers of refugees are arriving in
Malawi, many in poor health. Since January more than 7,000
refugees have arrived along the Mazoe river in Zimbabwe.
\CONT.

BRITISH RED CROSS • CAFOD • CHRISTIAN AID - HELP THE AGED • OXFAM - SAVE THE CHILDREN FUND

-2-

Tropical cyclones and drought have also taken their toll on the
country’s resources. The province of Zambezia, once considered
the country’s ’’bread basket” is now one of Mozambique’s most
stricken areas. From 1979-1984 the country was hit by drought
for five years in a row and drought again struck southern
provinces this year. Harvests of maize and rice, staple crops in
Mozambique, have fallen sharply. The collapse of the country’s
market economy has been a disincentive to farmers to produce more
than subsistence needs and has also contributed to the disastrous
drop in food production.
The Country
Mozambique is a large country bordered by Zambia, Malawi,
Tanzania, South Africa, Swaziland and Zimbabwe with 2,470 km of
coastline on the Indian Ocean. (See map). The largest city is
the capital, Maputo, (formerly Lourenco Marques) on the coast.
The climate is tropical in the north and sub-tropical in the
south. Mozambique gained independence from Portugal in 1975.

Needs
The Mozambique Government has established a major relief effort
through the Department for the Preventon and Combat of Natural
Disasters (DPCCN) but much more help is needed. The UN Food and
Agriculture Organisation (FAO) conducted a crop assessment
mission in March/April 1987. Their provisional estimate of food
aid required for the year to April 1988 is 674,000 tonnes, plus
tonnes, The UN system has also
other food requirements of 90,000 tonnes.
identified urgent requirements in other essential areas:
★
★
★

Health
Water Supplies
Agriculture
Transport

The UN system set up a special emergency office in Maputo and
earlier this year launched an appeal to governments for US$ 244
million. The British Government has offered £31 million both as
emergency aid (including up to 30,000 tonnes of food) and help
for long term development) through voluntary agencies and
government channels
Disasters Emergency Committee
DEC agencies have been present in Mozambique for a number of
years through international networks, local partners and field
offices. In
T response to the
’
*
‘ ‘
'
‘have stepped up
growing
crisis
they
relief within Mozambique and for refugees over the borders.
The following gives a summary of the work of each agency for the
people of Mozambique, Further details can be obtained from
individual agencies.

\CONT.

-3-

BRITISH RED CROSS, 9 Grosvenor Crescent, London, SW1X 7EJ,
Telephone 01-235-5454
The British Red Cross supports its sister society the Mozambique
Red Cross; both are part of the International Red Cross
movement. Red Cross action in Mozambique includes a prosthetics
programme for war amputees, among them children, and distribution
of relief supplies to 40,000 displaced people in Zambesia and
125,000 people in urban areas. A British Red Cross delegate is
in Mozambique identifying priority needs. The British Red Cross
has chartered a ship to carry medical supplies, food and tents up
the Mozambique coast.
It has already shipped out clothes for
10,000 people. The Red Cross network also helps refugees from
Mozambique in all five neighbouring countries.

CATHOLIC FUND FOR OVERSEAS DEVELOPMENT, 2 Garden Close, Stockwell
Road, London, SW9 9TY, Telephone 01-733-7900.
CAFOD works through Caritas Mozambique, the Catholic Church
agency for relief and development and one of the
longest-established agencies in the country, and is able through
national, regional and locally-based organisations to reach
communities not targeted by the government - for example,
displaced people who have no ration cards. Relief goods are
brought in mainly from Zimbabwe and distributed through Caritas'
local network of parishes. The main recipients are the old, the
sick, children and pregnant and breast-feeding women. CAFOD also
provides funds for programmes to help Mozambican refugees who
have fled to neighbouring countries.

CHRISTIAN AID, 240/250 Ferndale Road, London, SW9 8BH,
Telephone 01-735-5500.

Christian Aid funds the relief and development work of the
Christian Council of Mozambique (CCM) which works with the
Government's Department for the Prevention and Combat of Natural
Disasters (DPCCN) in the provinces of.: Maputo, Gaza, Inhambane,
Manica and Sofala. Food, seeds, tools, blankets and soap are
brought in by road or sea to Maputo and Beira. Through its
sister organisation Christian Care in Zimbabwe, CCM buys food and
other supplies for direct delivery to Tete province. In
co-operation with other Christian Councils and agencies in the
region, CCM is extending its programme to reach other northern
provinces and in June 1987 appealed for USD4.5 million.
Christian Aid contributed £350,000 to these programmes in 1986/87
and will be a major donor to following phases. It has provided
an administrator for six months to work for CCM. Christian Aid
also supports emergency programmes in all the five neighbouring
countries with Mozambican refugees.
\C0NT.

-4-

HELP THE AGED, St. James’ Walk, Farringdon, London, EC1R OBE,
Telephone 01-253-0253
Help the Aged has a Zimbabwe based representative and from
1982-1986 provided drugs for distribution through the Christian
Council of Mozambique.
In 1987 the charity granted £60,000 for
emergency relief - cloth, seeds, pullovers and blankets distributed by the Zimbabwe - Mozambican Friendship Association
(ZIMOFA) and Oxfam. Five thousand blankets have been shipped
from the UK. Help the Aged has also made grants totalling nearly
£40,000 to relief organisations in Zimbabwe, Christian Care and
the Drought Operations Committee, to help elderly Mozambican
refugees. The Charity has also employed an epidemiologist to
study the needs of elderly Mozambicans and identify appropriate
projects for it to support.

OXFAM, 274 Banbury Road, Oxford, 0X2 7DZ, Telephone Oxford (0865)
56777
OXFAM opened a permanent office in Mozambique in 1983 and is
involved in development programmes particularly in the north.
Since 1984 OXFAM has funded substantial relief programmes and in
1986 the escalation of the war led to a sudden increase in the
scale of operations, with £5.3 million allocated (in cash and in
kind) over the first few months of 1987. OXFAM works through the
agencies of the Mozambican Government, particularly the relief
department, and has concentrated on provision of clothes, seeds
and tools to the destitute in the provinces of Zambezia, Niassa
amd Tete. An airlift is being organised (with Norwegian Redd
Barna) to carry urgently needed supplies to remote areas, and a
trucking operation is being organised in association with Band
Aid.

THE SAVE THE CHILDREN FUND, Mary Datchelor House, 17 Grove Lane,
Camberwell, London, SE5 8RD, Telephone 01-703-5400
The Save the Children team of seven expatriates and 20 local
workers has been working in Mozambique for three years.
It has
concentrated its £1.4 million programme of emergency aid in
Zambezia, one of the worst hit provinces. This includes food,
cooking utensils, seeds and farming tools and the transport to
deliver those essentials to displaced families and those willing
to look after lost or orphaned children.
In addition SCF’s
long-term development work, essential to the rebuilding of the
country’s shattered economy, is running at well over £300,000 per
annum.

Save the Children plans to spend money from the emergency appeal
on the running costs of 25 trucks being shipped to Mozambique for
emergency aid.
See over for details of how to make payment.

/CONT.

•

\

If you would like to contribute to the Disasters Emergency
Committee appeal for Mozambique, you may do so in any of the
following ways:

directly at any bank, post office or main building society
- by credit card, by telephoning 01-200-0200
- by sending a cheque or postal order to this address:
Emergency Appeal for Mozambique
PO Box 999
London EC2R 7LD

4

MOZAMBIQUE

*•

TANZANIA

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Help the Aged
THE TIME TO CARE IS NOW

St. James’s Walk London EC1R OBE
Telephone: 01 -253 0253
Telex: 22811 HELPAG G
Patron: HRH The Princess of Wales

■

Help the Aged is a national charity dedicated to
improving the quality of life of elderly people in need
of help in the UK and overseas. We pursue this aim
by raising and granting funds towards community­
based projects, housing and overseas aid.

MOZAMBIQUE
The situation in Mozambique continues to worsen as the combined effects of
war and drought drive more people from their homes, forcing many of them
to abandon their livelihoods and all their possessions. Over one-third of
Mozambique’s fourteen million people are severely affected. Elderly
Mozambicans are particularly vulnerable as the family support system on
which they are dependent is breaking down under the effects of this
destabilisation.

Over the past five years Mozambique has suffered a serious economic
decline brought on by years of drought and MNR attacks on key industries,
road and rail transport. Food production and essential services have been
disrupted, resulting in widespread shortages of food, clothing and other
basic items such as soap.
Recent visitors to Mozambique report that guerilla activity is increasing
in the northern provinces of Mozambique. In Tete province it is becoming
very dangerous to travel by road, and villagers in some northern areas are
so terrified of rebel attacks in the night that they walk up to twenty
kilometres to sleep in the nearest towns. There is little food in the
area, and villagers have to eat their cash crops to survive.
Within Mozambique itself there are four million displaced people but no
organised transit camps; those forced to leave their homes head for refuge
in the ’secure’ towns. People with relatives in towns stay with them - in
some cases there are up to three families living in a house built for one.
Of the million or so Mozambican refugees in other countries some 80,000
are in Zimbabwe, 40,000 in camps. A fifth camp is being planned in the
S OU th .

Chairman Peter Bowring
Director General John Mayo OBE

o

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Company limited by guarantee
Registered in England No. 1263446
Registered Charity No. 272786

Cathy Squire, Help the Aged’s Asssistant Desk Officer for Disaster
Response, returned last weekend from a visit to the Zimbabwe camps for
Mozambicans to assess the situation. She reports that the camps are very
isolated and that conditions are poor. The land may not be used for
farming, and efforts to create an economy through skills training are
severely limited because the locality is poor and there is not a large
market for products. Some refugees work on the local commercial farms for
starvation wages. Refugees who have been in the camps for some time are
relatively well cared for, but the resources are inadequate to cope with
the daily new arrivals. In the northern camp of Mazoe River Bridge up to
forty refugees cross the border daily seeking shelter and security.
Describing the conditions of the new arrivals at Mazoe River Bridge, Cathy
said, ’’The children were very thin and almost all of them had chest
infections, colds and coughs. There were significant numbers of elderly
refugees, and most of them were sitting around listlessly as there is
nothing for them to do. As it is winter the nights are extremely cold with
temperatures approaching zero. In many cases whole families have only a
single blanket and have to sleep on the ground.”

Kamil Piripiri and his wife Fania Sumbereru are both over 65 years of age,
and lived in the Tete province of Mozambique as peasant farmers. Their
two children who are married with families also live in the displaced
people’s camp in Nyamatikiti, northern Zimbabwe. Kamil and Fania left
Tete in 1983 because of drought, hunger and the war. As peasant farmers
they used to grow maize, sorghum and groundnuts. In the camp they grow
tomatoes, paw-paw, and other green vegetables and fruit to supplement
their daily diet of maize porridge (Sadza) with beans or with fish
(Kapenta). They would like to return to Tete when the government of
Mozambique is ready for their resettlement. They would need farming tools
such as a hoe, axe, and spade, and seeds for at least the first year.
They want to live independently of their children who have their own
families to support.
Help the Aged has employed an epidemiologist on a short-term contract to
study the needs of this group and to identify appropriate projects for the
Charity to support. Help the Aged has a representative based in Zimbabwe,
and from 1982 to 1986 provided drugs for distribution through the
Christian Council of Mozambique. In 1987 the Charity has granted £60,000
for emergency relief - cloth, seeds, pullovers and blankets - distributed
by ZIMOFA and Oxfam. 5,000 blankets have been shipped from the UK
directly to the Mozambique Ministry of Health. Help the Aged has also
made grants totalling nearly £40,000 to relief organisations in Zimbabwe,
Christian Care and the Drought Operations Committee, to help elderly
Mozambican refugees with shelter and clothing.

In 1963 the Disasters Emergency Committe (DEC) was set up to provide
British aid agencies with a channel of co-operation for emergency relief
overseas after large-scale disasters. Help the Aged joined the DEC in
1986 as an associate member.
’ * x
xx \ on 24 June 1987 with a four minute
The DEC launched its Mozambique
appeal
broadcast after the BBC ’’ 9 O’clock News’, and the ITN ’10 O’clock News’.
On 25 June the appeal will also be broadcast after Radio 4’s ’World at
One’ programme. The name of the appeal is ’Emergency Appeal for
Mozambique’, and the Post Office and all main banks will accept donations
for it.

2

Help the Aged’s share of the funds will be used for immediate relief
programmes, such as the provision of food, clothing, seeds, soap and
blankets for elderly Mozambicans. The Charity plans to support public
health programmes and hopes to assist income-generating projects for
communities supporting elderly people. Help the Aged will also support
programmes through Mozambique’s Ministry of Health.

For further information, please contact:
Dee Sullivan
Press Officer

24 June 1987

3

I
Help the Aged
THE TIME TO CARE IS NOW

St. James’s Walk London EC1R OBE
Telephone: 01 -253 0253
Telex: 22811 HELPAG G
Patron: HRH The Princess of Wales

£0^Help the Aged is a national charity dedicated to
improving the quality of life of elderly people in need
of help in the UK and overseas. We pursue this aim
by raising and granting funds towards community­
based projects, housing and overseas aid.

T:ete

^)3ne

MOZAMBIQUE,.^

Background
Over one-third of Mozambique's fourteen million people are seriously
affected by war and hunger. Ten per cent of the population is over
fifty years old. Many people are destitute, having been forced to flee
their homes, are suffering from malnutrition and have little or no
clothing.

The economic situation in Mozambique has been poor ever since the 1983-4
drought, but the sudden deterioration over the last six months is not
principally due to drought but to the escalation of the South Africanbacked Mozambican National Resistance (MNR) activity. The rebels have
been active mainly in the districts north of the Zambesi river, but
especially in the districts bordering on Malawi. This consists of
widespread attacks against population centres and sabotage. Villagers are
attacked, crops and homes burnt, local government workers, teachers and
health workers killed, and wells poisoned by dumping dead bodies in them.
Villagers are forced to leave their villages and congregate in and around
urban areas. Many have fled to Malawi, Zambia and Zimbabwe.

Chairman Peter Bowring
Director General John Mayo OBE

I

Company limited by guarantee
Registered in England No. 1263446
Registered Charity No. 272786

MNR guerillas systematically target key food and other industries, and
disrupt road and rail transport with mine and rocket attacks ,
Agriculture employs nearly 85% of the labour force and provides the buik
of exports. The major products are cashew nuts, shrimps, cotton an
maize Industry accounts for only 10% of national income and is
concentrated i^ agriculture processing and textiles, particularly in the
Maputo region. Exports are mainly agricultural, but the largest s^gle
foreign currency earner has been remittances from miners working in South
I^icI? Aspite falls from this source following recent repatriations.
Trade has fallen sharply in recent years, having been severely disrupted
by outdated equipment and by MNR activity destroying the country s
transport system. Agricultural production has also dropped qui e
dramatically since 1981 due to droughts and MNR activity. Food shortag
cause malnutrition, and the health services are unable to respond
adequately
Supplies of many commodities - soap, clothing, seeds an
Sols food, trucks - are scarce and difficult to distribute to areas in
need ’even when available, because of the danger of terrorist attacks
X; XL «« . direct cause ol th. present fn.ln. .nd th.
»

.» many thousands of people having to flee their homes.
for relief agencies operating in Mozambiflue are exacerbated by the fact
that MNR activity is directed at them. The overall situation is further
aggravated by the drought in the southern provinces of Gaza, Inhambane an

Maputo.
Over the past five years Mozambique has suffered a serious economic
d"LSby «uee..=i». y«= »£ drought and flooding, by . lath
“Xt managerial staff and inadtnoate o.plt.l investment and

above all by war and foreign destabilisation. If stabili y
restored the country does have the resources to achieve steady growth.
But any real progress will depend on peace, and the prospects for that in
the immediate future are less than favourable.
*, one million are refugees in
Of the five million people seriously affected,
other countries -- mainly
mainly in
and Zambia
Zambia - and four mill!
in Zimbabwe,
Zimbabwe, Malawi
Malawi and
are displaced within Mozambique, mostly in Sofala Zambesia
Tete^
Manv of the displaced people are living in transit camps. Conditions
in these camps are poor, with most people sleeping in the open and many
suffering from malnutrition and disease.

Help the Aged in Mozambique

representative based in Zimbabwe, and since 1982 has
Help the Aged has a
provided the following assistance for Mozambicans in Mozambique:

1982

15 tonnes of used clothing donated to Ministry of
Health for distribution

1983

Consignment of drugs to Christian Council of
Mozambique for Minsitry of Health

1984

Consignment of drugs to Christian Council of
Mozambique for Ministry of Health

2

1986

Consignment of drugs to Christian Council of
Mozambique for Ministry of Health

The Charity has also assisted displaced Mozambicans in Zimbabwe:

1984

£4,000 to Christian Care for general relief programme

1984

£2,000 towards setting up the Drought Operations
Committe

1984

£12,000 for general relief spent through the Drought
Operations Committee

1984

£20,000 for general relief spent through the Drought
Operations Committee

In 1987, Help the Aged has provided the following:

£10,324 on cloth, sewing kits and blankets purchased in Zimbabwe
to be distributed by the Zimbabwe-Mozambican Friendship
Organisation (ZIMOFA) in Tete

5,000 blankets to be shipped from the UK (about 4,000 already
gone)
£15,076 spent on pullovers purchased in Zimbabwe, which Oxfam
will distribute in Niassa
£10,000 spent on seed for Tete which will be distributed by
ZIMOFA
£20,000 contributed to Oxfam’s seed programme in Niassa

Because of the problems of communication it has been difficult to assess
the numbers of affected elderly people there are. Often they are the
’hidden refugees’ and go unrecorded by other agencies. Help the Aged has
recently sent a representative to Zimbabwe to assess the actual numbers
and situation of elderly Mozambicans.

The problems of distribution to those in need which are caused directly by
MNR acitivites mean that Help the Aged works very closely with other
agencies operating in the area, such as Oxfam and ZIMOFA.

For further information, please contact:
Dee Sullivan
Press Officer

11 June 1987

3

fA17.

Werner & Bower cauiion us that there is often a sting in the tail when pe^.e

advocate community p articipation:

Participation
as a way for
people to gain control

Participation
as a way
to control people
How can we get them A
to do what we want?^/
jr why not through ^
I
'community
i
participation'? We
\ can get international
funding!

/
X
ZnowcanA
/ we ge a \
fairpnce
\
\

,or OU^
grain?

J

Xwhv not join\
/ together, rent \
a^ck.and
transport it
/
to market /
ourselves?,/

I 1 /
/X \JM.
/But what will
lothing-X
the landif we
. owner sa/^. _
stick
^y^together^

Source: Werner and Bower, 1982:6-13

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Backpage

74

WHAT earlier promised toemerge as a stable coalition
the centre and in a few crucial states, it has been
has now started displaying cracks. The current fra­
unable to place Article 370, Uniform Civil Code, what
gility ol the National Democratic Alliance owes little
to speak of the temple at Ayodhya on the agenda, even
to the self-activity of the opposition parties; they con­
if on the backburner. Its preferences about swadeshi
tinue to be mired in a morass of self-delusion and
stand sidelined in the frenzied search for foreign capi­
squabbling. The problem is entirely an internal one.
tal and the rush to meet WTO guidelines; the commit­
The BJP, principal partner in the NDA, appears cor­
tee to review the Constitution ignores it and makes clear
nered. And contrary to expectations, the strains have
that the basic structure will remain unaltered: even
been created not by a minor partner misbehaving and
national pride has been given a go by, if the supplica­
demanding more than its due share, but by its ideologi­
tion displayed during the Clinton visit is any indication.
cal fountainhead, the RSS.
None of this can go down well with those who
For nearly a fortnight, instead of debating the
believe that they live by valuesand principles. Worse,
implications of the much touted millennium budget,
those faithful deputed to keep the party on ‘the straight
the Parliament was caught in a logjam. The opposi­
and narrow’ themselves seem to have been corrupted
tion stalled all proceeding demanding that the Gujarat
by the lure of power.
government revert its decision allowing government
Is this because the basic relationship between
servants to take part in the activities of the RSS. Though
the BJP and the RSS is altering? If in the past the BJP
the central government pointed out that it had no con­
appeared dependant on the RSS, not just for ideologi­
stitutional locus standi in the matter; that the RSS was
cal coherence but for dedicated cadres duringelections,
ahighls respected.non-political,soqio-culturalorgani­
the situation today seems to have been reversed. The
sation: and the RSS leadership itself clarified that it had
BJP, by reinventing itself, enlarging its social catch­
not sought the revokation of the ordinance listing it as
ment and engineering effective coalitions, has grown
a pioscribed organisation tor government servants —
from a 8% party to one garnering close to a quarter of
no one took these clarifications/protestations seriously.
the vote. The ability to dispense patronage and collect
Even the constituents of the NDA - the DMK.
funds has provided it relative autonomy from the RSS.
TDP and Trinamul Congress - made evident their
The RSS, on the other hand, like most ideologi­
displeasure. Finally, the government had to relent.
cally rigid cadre-based organisations seems to be fac­
Seniorparty functionaries were despatched to Gandhi­
ing difficulty in renewing itself. Its ability to attract
nagar to make the state government see reason. The
fresh cadres, particularly from among the ‘suitable’
matter was resolved, but the government lost face.
young remains suspect, despite claims about the phe­
More than ever before, the schism between the BJP
nomenal growth of the shakhas. Its efforts at social
and the RSS came to the fore.
engineering by opening up leadership positions to the
It has been evident for some time now that far
OBCs has often boomeranged. Rememberthe ‘revolts’
from beingjubilantabout the BJPcoming topowerfor
of a Kalyan Singh ora Shankersinh Waghela.
the third time, the RSS leadership appears extremely
Yet, it cannot quite afford to fundamentally rock
uncomfortable with the actions and pronouncements
the boat. It is still unlikely that any other regime would
of its ideological and organisational offspring. For
be more favourably disposed to it; the chances of a deal
years, and through some ratherdifficulttimes, the RSS
like the one with Indira Gandhi in 1980 remain low.
has held firm to its worldview. Over time, those sym­
So all it can do is to fester in anguish, episodically
pathetic to its Weltanschauung have grown in numbers.
inflicting pinpricks through a Murli Manohar Joshi,
It has even acquired legitimacy in the eyes of the
the flavour of the season. The recent elevation of
modem, urban middle class, more specifically those
K.S. Sudarshan as the Sarsanghchalak makes clear
belonging to the upper caste-class strata. •
that the RSS is unwilling to live with its marginali­
It now faces the discomfiting situation of many
sation. If anything, it will seek to reassert itself. Clearly
of its favoured formulations being sacrificed at the
we have interesting, and dangerous, times ahead.
altar of pragmatism and coalition dharma. Despite
being in power (though through a surrogate) both at
Harsh Sethi
Ageing

r
we ourselves may want to revise later in the light of
disagreements or new evidence.
Just as the critique ofessentialism has come full
circle, raising several uncomfortable questions for
social scientists, the emphasis on action research that
has been so much a part of the anthropological criti­
que since the 1970s has rebounded on the academy.
The need to promote multi vocality ordialogue within
participant observation or the need to rethink ways in
which anthropologists could help and repay people
with whom they lived and studied led to the promo­
tion of advocacy and development anthropology. The
latter had the additional benefit of creating full time
employment as anthropologists promoted themselves
as virtuous ‘bottom up’ members of‘top down’ teams.
Increasingly, however, the idea of proactive
research is being taken away from the universities
and placed within the domain of NGOs and consult­
ants. Research that directly feeds into development
projects is seen as action research. From the point of
view ot society or funders, there are many advantages
to research being funded outside universities. For one,
NGOs are often able to identify new issues, when aca­
demics are bound by the conventions of their field or
by whatever theory is fashionable at the moment.
Environment comes to mind, for instance, as a good
example of a field where academic research has
piggybacked on activist research. Other examples
include feminist research, philanthropy and urban
planning. NGOs are also often quicker to produce
resultsand in a form that can be used by practitioners.
At the same time, there are several dangers in
letting donors and NGOs define what is proactive
research, and simultaneously define the proactive as
the politically correct. First, research that is ostensi­
bly done in collaboration with the subjects in pursuit
of a particular agenda is glorified with the name par­
ticipatory research, without questioning whether the
agenda itself, such as joint forest management or fam­
ily planning, is something that was developed in par­
ticipatory fashion. Second, once a subject becomes
fashionable, there is a tendency for people to jump on
the bandwagon and produce endless case studies, many
of which have limited value. Certainly, very little jus­
tifies the amount of funding that goes into such case
studies with consultants charging fees that range from
2500-3000 a day. Third Jhe amount of money that goes
into so-called research consultancies also undermines
research that goes on in universities. It is hard for
universities with comparatively limited resources to
retain people, and besides, the pressure of having to

compete with such organisations for funds means
that much research in universities also tends to become
project oriented, short term and driven solely by
whether or not there are any policy implications.
Finally, what tends to happen as a result of such donor
driven research is an excessive focus on the poor as
against a focus on the rich, on the presence or absence
of social capital among the poor instead of how the
practice of capitalism impedes development in a
systematic manner.
Clearly, there is a need for research, whether
inside or outside universities and unless universities
and academic institutions clean up theiract first, they
are in no position to complain. Perhaps the first step
towards proactive research, then, would be to direct
attention to one’s own institutional setting. Teachers
who don’t take classes, the practice of Ph.D super­
visors hiring their own students as soon as they become
heads of department, and all the myriad sins practised
by academics need to be studied and written about.
There was no protest, for instance, when a national
research institute in Bangalore used the excuse that
the rules did not permit someone without an MA in
sociology from becoming a professor of sociology
simply in order to keep someone out and appoint
an internal candidate. Never mind that the person
excluded just happened to be India's leading environ­
mental sociologist. Such egregious nepotism, not by
Hindutva activists or Marxists, but simply middle of
the road, unremarkable academics, is exactly the sort
of thing that lays the ground for far more dangerous
ideological nepotism. Only if one tackles this will
one be in a position to tackle the problem of political
correctness in the Academy and ensure that research
is judged by intellectual merit and not just by who is in
aposition of power at any given time.
NandiniSundar
References

A. Baviskar. ‘Tribal Politics and Discourses of Environmental­
ism’. Contributions to Indian Sociology (31). 1997, 195-223.
P. Brosisu. 'Analyses and Interventions: Athropological Engage­
ments with Environmentalism'. Current Anthropology 40(3). June
1999.277-309.
K. Gough. 'Anthropology and Imperialism Revisited’.Economic
and Political Weekly, 4 August 1990. 1705-1708.
D. Gupta. ‘Survivors or Survivals: Reconciling Citizenship and
Cultural Particularisms', Economic and Political Weekly 34(33),
14 August 1999,2313-2323.

A. Sundar. Sea-Changes: Organising around the Fishery in a South
Indian Community, in J. Barker et al.. Street-level Democracy:
Political Settings at the Margins ofGlobal Power. Kumarian Press.
Hanford, CT. 1999,79-114.

SEMINAR 488 - April 2000

73

•**

M

O

I (
I

How to meet old age and lead a
i”
happy life
B.in ■

Prof. P. Nataraj

I.

THERE are many popular notions about
old age. "Old age is the last stage of the
life's jouruey". "Old age is the living grave"
"Old age is the reversion to childhood or
it is a second childhood"; but the only
difference is that childhood marks the
beginning of life whereas old age marks the
ending of life. ' Old age is man's most paradoxical and contradictory stage of life—
wherein arises the life’s last question, de­
manding solution but is unresolvable".
"Man is as old as he feels" and "Woman
is as old as she appears." So the feeling
of old age begins in mind before it sets in
reality. Some yield to the onslaught of
age as under the power of a magnet and
start growing old; whereas a few challe­
nge the approaching years of old age boldly
and strive to maintain zest for life. Sir M.
Visveshvaraiah, Sri Shivarama Karanth,
Mahatma Gandhi, Mother Theresa are the
good examples for this. George Sokolsky
says "Years are only artificial mark­
ings on Calendar. If the spirit is young,
the years are not even remembered. If the
spirit remains young one can sing a song
of youth even at eighty as at eighteen, but
it will have a new meaning and significa­

decline of the physical, physiological and
psychological faculties which are inevi­
table.
In old age, physically, the body shrinks,
the chest bends, the shoulders sags, the
skin wrinkles and loses its bloom; the
muscles lose their resilience, the hairs be­
come grey, scanty and lose tneir lustre;
the eyes shrink and lose, their brightness
and become lazy; ears become less respo­
nsive and develop high tone deafness;
gait becomes unsteady and so on. Physio­
logically, reflexes become slow, blood
vessels and muscles of heart become hard,
and B. P. raises; respiration becomes fast
and shallow, digestion becomes slow and
poor, excretory functions lose control and
soon. Psychologically social, emotional,
intellectual, motivational and creative
functions become slow. Learning, memo­
ry, perception, attention, thinking, reason­
ing and other psychological faculties also
become slow and decline in old age.
Personality starts losing its integration
and equillibrium.
Though ageing is an inevitable and univ­
ersal phenomenon,the rate of decline varies
from faculty to faculty and from individual

nce at eighty". "Old age is nothing but
unconditional surrender to the increasing

to individual. Some scientists hold the view
that "If we keep our interest grow with the
progress of the world, if our education con•
tinues to grow, if our sense of humour is
intact, if we do not overestimate ourselves

decline or deterioration which is a natural
process of age". Scientifically soeaking
old age is the period of deterioration or

12

3WARBHETRA ROSPITAL
Sovakshetra Hospital Road#

Banastamkari Hnd stage,
BANGALORE-A7n

I

and our own thought and at the same time
if we do not underestimate others and

their opinion, we no not grow old soon."
The old people are characterised by
a growing lack of self-assurance, anxiety
due to fears of loneliness or insecurity;
lack of interest in the world around,
grumpiness, irritability, depression etc.
Theybecome egoistic,egocentric and intro­
verted. Their range of interests shrinks and
start dwelling in past glory than the pres­
ent reality. They suffer from hypochondria.
They have poor control of their impulses,
emotions and reactions. Their percep­
tion, attention, learning, memory, intelli­
gence, sociability, emotionality, moti­
vation, creativity etc , start declining.

living, of use of time, of loss of partner, of
ill health, of loss of social status, of loss
of independence and of generation gap to
live with adult children and to deal with
youngsters in and around.
These should be looked in a constructive
way. Consult your personal doctor perio­
dically and have physical check up annua­
lly and maintain the records to follow up.
Then have balanced diet, moderate exer­
cise and regularity in doing all these things.
Also practice physical and mental relaxa­

tion atleast once a day.
Plan out your income from pension, rent
and other sources of income. Also list out
your requirements of food, clothing, hous­
ing, transportation, medical aid, taxes to
be paid etc. Match the two ; do not try to
ntroir h youi Ingfl beyond the Ircd.
Even before retirement, both the husband

This is the gloomy picture of old age.
Dohovlourol Irnbnlnncon npponr nt tho
early stages of old age due to harmonal
imbalance but equalibrium will be restored
in a short span of 2 or 3 years. On the

and wife should plan out where to live
after retirement. While so planning you

have to consider the climate, cost of living
facilities like medical, recreational and

otherhand if there are already predisposing

conditions like personality cranksor cleava­

shopping availabilitiy etc. Availability of

ges, emotional imbalance and impulsivity,
the stresses of the old age precipitate
- the existing conditions and cause senile
psychosis—involutional melonchoiia or

facilities to meet friends and relatives in
the proximity should also be taken into
account. To the extent possible live nea­

arterioselerosis and so on.

rer your children so that you or they can

A German Gerontologist distinguishes
three types of old age and aged persons.

visit as and when required.
Time is at yourdisposal after retirement.
Happiness and pleasure comes not from
rest but from doing something which is
interesting and rewarding. So list out
things you want do to spend time, their
order of importance and priority of doing.

(1) The Negativist who declines old age
and its qualities.
(2) The Extrovert who admits old age
and his changing position within the

family.
3) The Introvert who experiences ageing
on an intellectual and emotional plane.

Plan out these things before retirement,
so that youcan easilyswitch overto these

activities soon after retirement.
In order to adjust well and to deal effe­

Due to physical, physiological and
psychological decline or de ter io rat ion ci ted
earlier, many problems crop up or confront
the aged person such as problems of
health, of reduced income, of place of

ctively with the persons whom you love
and by whom you want to be loved,
try to understand how they feel and act

13

I
i

I

c*

with you. Cultivate youthful attitude and

mind and you are never too late to learn.

maintain interest in and acquaintance with

Learning makes a man fit company for
himself. To learn is to know. To know is

young people with whom you deal. Do
not be critical of what your adult chidren
do. Recognise them as grownups, treat

power and power is the captain of youth.
Respect the laws of health and maintain

them as friends and permit them to live
as they like. Try to think in retrospect how
you were, or are, not a carbon copy of
what your parents and grand parents were.
So, do not expect them to be your carbon
copy. This helps you to avoid the problems
of generation gap.

an everlasing enthusiastic perspective of
life. You cannot avoid or control your
calendar birthdays, but still you can remain
young in "mind and heart". So develop a
lot of interest in everything around, travel
now and then, have new things and meet
new people. There are many wonderful

Restrain yourselfwhen you havean urge

things to see and do. Thank God for
everything he has given you and for keep­
ing you on this earth. Learn to enjoy your

to comment on their doings. Do not impose
your views on them and do not harp on
your good old days. Try to keep yourself
up-to-date, so that you can converse with

living.
Forget your past mistakes and disappoint­
ments but learn to gain from your experi­
ences and live happily. Accept your phy­

them interestingly. Always keep yourself
tidyand attractive in your dress and appe­
arance to avoid causing embarassment. Do
not demand special attention and consi­
deration either at home or at a party, just
because you are older than them. Do not
allow yourself to indulge in self-pity.
Maintain your faith in God and believe
that everything is a part of the game and
take things sportively. Do not give advice
unless it is sought for.

sical limitations graciously; grow' old with
dignity, complain less and appreciate more.
Have time every day for mental and physi­
cal rest. Cultivate tolerance, understand­
ing, kindness and unselfishness from your
experience. Avoid egoistic and egocentric
behaviour. Do not worry over the future
but live at present. Learn to smile more
but frown less at everything. Do not add
vears to your life but add life to your
years. At the tail end of your life, live for
others' sake. Live gracefully, gratefully,
peacefully ana nappily.
©

Old couplemust stay in their own house
. as long as possible, because it is easier to
carry on the routine in a familiar setting.
Old age is what you have conceived in

-1-

Thanks to the human heart by which we live
Thanks to its tenderness, its joys and fears.
To me the meanest flower that blows can give
Thoughts that do often lie too deep for tears.
— Wordsworth

14

o

1

6. Suitable low cost health insurance
schemes should be provided for the bene­
fit of senior citizens.
7. A certain number of beds for geria­

tric group

should be

earmarked in all

hospitals.
8. A national day for senior citizens
may be observed every year like the child’ ren's day, in order to focus public attention
'

on the needs of senior citizens.
9. Free medical aid and special care for
the old should be made available to all
senior citizens in Govt. Hospitals and pri­
mary health clinics.

e

10. Free legal aid should be arranged to
help the senior citizens from being exploi­
ted by their own kith and kin.
An all out effort should be made to help
senior citizens to be self-reliant, co-opera­
tive with others and set a good example
to the rest of the community. The theory
of declining years refers to the body only,
Man must continue to grow mentally and
spiritually. The meaning and purpose of
life must be pursued with determination
so thar sufferings, loneliness and old age
can be transcended. The spirit is ageless.

Financial problems of the aged
and of Old age Homes
Rev : Fr. Dr. P.C. Eapen, M.A., Ph.d.(Nyu)

IN most of the developed and developing
countries, old age has become a very heavy

but opportunity to live a fuller life indepen­
dently. It is our social and moral respon­
sibility to keep the senior citizens self-

burden—a distressing ordeal. The prob­
lems of the aged and the ageing are be­
coming increasingly complex and frustra­

supporting, self-sufficient and contented.
We should persuade government and
public agencies to provide subsidies for
housing facilities. In Britain, home care is

ting. The time-honoured order of an in­
built social security of the traditional joint
family system is slowly giving place to a

supplemented by Home Help service. Meals
on wheels and Day-Care Centers designed
to cater to the sociai and cultural needs of
the senior citizens. It will be worthwhile
to establish community service centres, to
be maintained by service clubs like Lions,
Rotary, Freemasons etc., for organising
seminars, workshops, cultural and recrea­
tional programmes for and by the senior
citizens.

narrowly selfish, rugged individualism
bereft of any human touch. The ever grow­
ing urbanization, the disintegration of the
joint family, the emergence of the nuclear
family, modernization, mobility, social
change and the influence of the industrial
culture have made deep inroads into our
highly spiritual heritage and value system.

By the turn of the century, the population
of the aged will reach a staggering figure

Special Travel passes should be made
available to senior citizens with provision

of nearly 76 million. Poverty and destitu­
tion, predicament of husband and wife

for reserved seats on trains, buses and in
theatres. Voluntary social agencies should
be requested to arrange for the supply of
free travel aids such as portable and fold­
ing wheel chairs, light travel bags, canes,

going to work, aping the West and forgett­
ing our culture, lack of respect for the
elders by the younger generation and above
all, economic degradation due to the esca­
lation of prices of all necessities are the
main problems affecting the aged today.

walking sticks etc. The Social Welfare
Department should be urged to issue iden­

In our country, medical science has cer­
tainly helped to add years to life; but
precious little is done to alleviate the phy­

tity cards to enable senior citizens to
secure various social security benefits and

to get atleast 50% concession, if not full
at hospitals, clinics, medical stores, libra­
ries and cultural programmes.
In the developing countries like India,

sical, financial, social and psychological
problems the aged have to confront. The
Senior citizens need, not ourpity or charity

20

the disabilities arising from ageng will be
compounded by those arising from poverty

to is not necessarily comfort in solitary
splendour, but certainly an opportunity
to be an active part of the society in use­
ful ways which will lend them dignity and
emotional satisfaction.

and under-nutrition, since a considerable
proportion of senior citizens do belong to
segments of the population below the
poverty line. At present in our country,
institutional arrangements and services

Following are some suggestions :
1. A national council for senior citizens
of India be constituted as a statutary body

designed to mitigate the problems of the
aged are extremely inadequate. Our objec­
tive however, should be not just to ensure
the survival of the elderly ; rather we must

to function at the national level with state
level committees in each of the states and
in union

help them sustain their productivity and

enjoy a good quality of life. Support to
the elderly should therefore be more than
a philanthropic 'charity' operation. By
harnessing the rich experience of the
senior citizens for productive endeavours,
we will be adding to the Nation's wealth.

of Indian Union

to

ing of various types of homes established
for the welfare of senior citizens
2. The Government of India be urged
upon to immediately formulate a national
policy on the "senior citizens" of the
country with necessary provisions relating

An imaginative national policy should see

them not as 'dependents’ but as a valuable
component of our national human resour­
ces.

i

territories

identify and strive to fulfil the needs and
aspirations of senior citizens of India as
also to productively utilise their rich ex­
perience besides assisting proper function­

to financial assistance for the projects
and programmes that are under way and
those to be framed in future.
3. The Union Ministry of Railways be
approached with a request that senior
citizens of 58 years of age and above be

Allocations for the welfare of the aged
and arrangements for this purpose must
find adequate focus in our rational deve­
lopmental programmes. The case for the
aged1 must not be perceived as largely
resting on “humanitarian" but on economic

allowed railway concession upto 50% in

grounds. The case for reasonable alloca­
tions for; the welfare of the aged will
therefore need to be convincingly articu­

both 1 st class and 2nd class railway tickets
without any stipulation on minimum or

maximum distances.
4. The Government of India and all state
governments and union territories within
Indian union be urged upon to provide
suitable government land free of cost for
the establishment of old age homes.
5. All the institutions established for the
welfare of senior citizens and presently
granted exemption at 50% for deduction
under section 80 G of Income Tax Act
1961, be modified for 100% deduction
from taxable income for all payments made
to such institutions by the assessees.

lated on a scientific rather than just a
sentimental basis,
We should not blindly copy the west.
Old age homes where senior citizens feel
lonely and isolated, however comfortable
and posh they may be, are not in conso­
nance with our culture. We will perhaps
not be able to do without them either. But
the real challenge is to ensure that our
policy withrespectto the agedreflects our
national heritage and value system. What
the seninor citizens normally look forward

21

o

f

■ The Status of the old in Rural
Areas
Vani Venkataram

THE case of the aged infirm in our society
makes an interesting sociological study.
The child grows to be a man ; the man
works hard till he reaches old age; thereefter he deserves all kindness and consi­
deration, so that the rest of his life may be
peaceful. To achieve this, the attitude of
the younger generation for whose benefit

from their original rural areas ; and when
once they taste the comforts of city life,
they do not wish to go back to villages.
This increasing tendency has caused total
disruption of the social structure in the
rural areas.

There is a general concept that the old
people in rural areas are different from the
urban ones. Of course, there is logic
behind this impression. People living in
urban areas have the taste of scientific
technological development which has not
penetrated into the rural areas. The popu­
lation explosion and concentration in
urban areas have affected the lives of the
people. People are facing grave economic
problems due to the shortage of job oppor­
tunities and tough competitions in every
field. There are many material attractions
for the urban people. People with or with­
out money want to possess these materials
above everything else. Greed and avarice
have increased and people are self-centred
andselfish. The values that were cherished
from ages galore in our society have been
sacrificed at the alter of insatiable greed.
This has led to the truncation of an other­

the old haveslogged, isof vital importance.
To ensure the development of such an
attitude, educating the younger genera­
tion at home and in school on the right
lines is of immense value. The education
at home is the concern of the parents;
likewise, the education at school is the
responsibility of the teacher who should
regard this as a sacred duty towards the
young growing minds. In the curriculum
of studies for the primary and middle
schools, moral education must find a place

so that this will act as a firm foundation
for the development of the mind.

Thereare a fewimportant causes for the
present dayproblems facing the old people.
One is the break up of the joint family sys­
tem owing to the fast changing social and
economic conditions. The opportunities
for employment in one's own place being
limited, the young ones migrate in search
of jobs leaving the elders to take care of

wise nurtured ways for smooth living. The
old are not treated as in olden days. The
younger generation in thair process of acq­
uiring alien cultures do not show respect,
concern, care and love to the older people.
There has been a feeling of insecurity and

themselves. The attractions of the urban
life naturally take away the young ones

24

i

r

unrest that has sot in amongst tho old
peop e, which is compelling them to find
other ways of getting peace in their lives.
As we all know this search has given rise
to formation of old age homes. But then,
this is not unique to urban areas alone.
t Pernaps, in urban areas the stress and

struggle have led to these problems. If
this alone is the cause then the ural old
should be enjoying utmost veneration,
respect, care and love from their filial
ones, being isolated from the urban areas

cue to inadequate communication. But, on
the contrary, the status of the rural poor is
still morepatheticand pitiable. Thepeople
in rura. areas have always lived in poverty
with hand to mouth existence. Every mem­

ber of the family works hard to earn his or
their two meals. Their economic backward­

ness seems to be an abysmal well from
which there is no escape. When people
grow old they become totally dependant
on tneir children. Now it is the turn of the

=?

younger ones to slog to make both ends
meet. Tneir meagre earnings should feed

without nagging. She receives ragi ball at
7 a.m. and the next meal at 8 p.m. She is

hurled with all kinds of abuses and insults.
Most unhappy person indeed, waiting for
her end in this world.
Janamma : She is shunted between her
sons. No one iswilling to keepher perma­
nently. She has become the target of her
children's envy and compeition. She feels
that after thewives have come the mother
is a total stranger to their sons and they do

not show any affection.

Chikkamma: She lives with herdaughter.
The daughter is a worker in a field. She
keeps taunting hermother often and wants

her to go to her sons. There the daughtersin-law do not want her presence. This

kind of cruel, inhospitable treatment has
made her so unhappy that she prays to God
to give her freedom from this earthly
shackle.
Judging by all these, whether rural old
or urban old, there is very little difference

.more mouths in the family. This naturally
leads to frustrations, unhappiness and un­
pleasantness. The old people are, time and
again, tauntedand insulted, andcompelled
to realise tltf fact that tkey are regarded

in human behaviour. Ultimately, it all
depends on individuals and the goodness
and values that are nurtured in them.
Human beings are tho same wherever

as a burden, Atleast the urban middle
class would have some financial cushion

they are. So it is a misnomer to think that
the rural old being cut off from so called
modern civilisation, are able to enjoy more
security, better status and peaceful life.

in most cases; but tho rural old have noth­
ing to lean upon. The facts gathered in

interview held with a few old people are
cited below:

The only solution seems to be in giving
training to the children from very young

Sidhaiah : Lives with his old wife, He
has a small home of his own and is not
dependant on his children. Wife, though
old, break stones, brings home enough
money for their food. He says when he
falls sick his children show kindness.

4

and dauglitor-in-law. Tho daughter-in-law
does n'ot feed her enough and that too not

age and prepare them mentally to under­
stand the social problems and cherish the
basic values. The regard, respect and care
for the older generation have to be practi­
ced by elders to show as an example to
the children. Unless proper education in
this matter is given, the solution to the

Maramma : A widow stays with her son
<

25

problem of the old people will permanently
remain a distant dream.
In this context, mention has to be made
of the conditions prevailing in developed
countries. In U.K. and U.S.A, the Govern­
ment is alive to the needs of the aged and
infirm, and hasintroduced several amelico-

e

rative measures. Senior citizens, as the old
are called, are given concessions for entry
into some places of entertainment. Old
agepensonscheme is in operation. Govern­
ment agencies extend courtesy and kindn­
ess to the senior citizens. Our great
country, India, should try to emulate them.

I'
/

,A-

j; .•

Elder Citizens and their impact
on Society
Sri M. S. Chandrasekharaiah

i

THE influence exercised by elder citizens
on society will be analysed under two
heads. These two influences are political
and cultural. The latter term signifies the
leadership role of the elders in the field of
social reform, education and the preserva­
tion and perpetuation of our heritage.

There is another very important factol
that strengthens the political or electora
influence of the senior citizens. The senior
citizens as a rule go to the polling booths

in very large numbers. In America the
average voter, as in India, isapathetic and
cynical. A voter turnout of 50% or 52%
is considered to be very good indeed. But
the senior citizens are keen voters and
enjoy the reputation of forming the largest
segment of active voters. In the midst of
general indifference and poor turnout, the
votes of the senior citizens can make or
unmake the political fortunes of many can­
didates.The candidates cultivate the elect­

The political role maybe considered first.
In the Western world the older citizens
constitute a very powerful and influential
voting lobby. In the U.S.A, for instance,
right from the President down to an ordi­
nary State Congressman (i.e., as distinct

from the morepowerful U.S.Congressman)
all pay careful attention to whatthe senior
citizens advocate as a group. The reasons
for this are many. In the west the senior

oral support of senior citizens a nd when ele­
cted they strive for legislation helpful to
the older people. The lobbies of the senior
citizen monitorthe elected representatives,
voting pattern in the Congress and hence
succeed in extracting many concessions

citizens form a relatively large segment of
the society because of better living condi­
tion and health care. Their longevity is also
great. They are all literate and many of them
are highly educated. There isa good sprink­
ling of professonal people among them.
Most of the senior citizens there are finan­
cially better off-with pensions being not
very much below the last pay drawn.Almost
everybody gets some social security pay­
ment. So the senior citizens are vocal,
articulate and can afford to contribute
to the campaign funds of such candidates
as are willing to press for legistation
favouring the cause of the older citizens.

helpful to the old. That is how the senior
citizens in the West got a good medical
and health care system, enhanced old age
benefits, concessional tickets for travel in
the public transport system and concessio­
nal tickets for cinema and theatres. It is
these extended and enhanced financial
and physical amenities that have enabled
the senior citizens to play a vital role in
their society.
But the position of the elder citizens in

15

I -

is pathetic. The vast

failaltogether. ASanskrit commentruns as

majority of the old here are illiterate, and
dismally poor. They are totally unaware of
the issues facing them or of their role,
struggling as they are to get the days' ration
of rica or kerosene. So they do not consti­

follows "Vardhakye Sarvendriyani avidheyah putra iva vartante." In old age all sense
organs behave like disobedient sons. A
few may even have to face terrible tragedies
such as the death of a spouse or a loved
member of the family. But let nobody be
disturbed unduly by this grim side of life.

India by contrast,

tute in anyway a voter's bank capable of
drawing attention to itself. These people

The strengths of the old are their high
degree of maturity and the courage of their
hearts and mind. But maturityand bravery
of the heart are not by themselves enough
to enjoy a smooth sarlingfor the old. The
society i.e.,the state has to provide some
basic amenities to the old and the state
will not do it till the senior citizens make
themselves heard. There is, for instance,
no national system of medicare. The
government sponsored General Insurance
Corporation excludes from the purview of
mediclaim those who are over 70. Actually
it is this group that requires most, the
benef it of the medicare scheme. Many old
people suffer from the terror syndrome of
falling so ill as to need hospitalization.
Yet again we do not have a national
and
rational
scheme
of old
age
pension. What exists is a mockery and is
only a political racket. The senior citizens
do not enjoy any real concessions by
way of amenities in the diverse walks of
life. Better old age social security
payments and a provision of efficient
health care are not to be viewed as
charities grudgingly given but they are
really deferred benefits merited by a long
stint of service. But this will be done only
when senior citizens form a good lobby.
They have to argue their case forcefully
and exercise their vote at the hustings of
the ballot.

instead of influencing the candidates are
themselves easily misled. No party pays
any heed to them as a group because it is
unorganised, inarticulate and unaware.

The few small groups of senior citizens
comprising of intellectuals and leaders in

different walks of life find that their plea­
ding for the cause of the senior citizens
goes unheard. Their appeals are brusquely
dismissed. One may mention here how

unceremoniously and disdainfully the
Government of Karnataka withdrew bus

passes of the senior citizen; in the name of
economy ! The point to be stressed here
is that senior citizens have got to work as
a powerful voter lobby whatever be their
own personal political loyalties. Otherwise
they cannot improve their social conditions.
This is importantforthe following reasons.
Most senior citizens grow beset with
problems, many of which are not of their

making. These are the problems of redu­
ced income, increased financial responsi­
bilities, i.e., marriage of a daughter
to be arranged or the higher education of a
son or daughter to be financed ; or debts
incurred earlier in similar contexts may
become due for repayment. This is also the
period ofreduced physical stamina, failing
health when Inertia due to age takes its
toll. A few may have chronic ailments. As
an English writer said "The diseases which
we acquire in our old age are our true and
lifelong friends". As the senior citizens
grow their sense faculty may weaken or

Once the senior citizens are provided with
minimum facilities to live a life of modest
the style, they have a great role to play in

16

|

o

*

society. They have always been esteemed
not simply because they are old. Mere
growing old does not call for any celebra­
tion. But the elders are the link between the
past and the future. They are inheritors as
well as the bequeathers of our heritage.
They have a great dealto communicate to
others because of their rich experience,
knowledge and aesthetic outlook. The older
citizens need to educate themselves in order

4

*

to pass on something truly worthy to the
young. The young do respectthe oldwhen
the latter have knowledge, wisdom and
values to pass on. It is only when the old
go on repeating some trivialities that the
young dismiss them as wasters of time in­
dulging in rigmaroles. The old, if not care­
ful, face the risk of entering anecdotage.
Useless reminiscences can lead to mere
reminiscences” if I can coin such a term.
The older citizens need to be well-versed in
some field of study and in some branch of
culture in order to enthuse our young and
to mould their tastes and to whet their app­
etite to know. Senior citizens who can speak
to their neighbours of a great book they
read, of the innovative work they did or of
the great music they heard can be wonder-

o

ful sources of informal and enduring educa­
tion. What the society needs is the type of

senior citizens who are themselves very
modern and path-breaking in their actions
and outlook. They have got to convey
right values and right task to the young.
This is very important today when the mass
media of information and entertainment so

easily dull and deaden the minds of their
captive audience. This is not the place to
go into the reasons for this. Enough to say
that our young are in the danger of be­
coming literate sophisticated philistines.
It is the pressing duty of senior citizens to
act as pockets of culture and wisdom. They
have got to inculcate worthy attitudes and
worthy ways in the sphere of intellec­
tual and cultural pursuits in order to trans­
form society and at the same time to make
it appreciate its great cultural heritage. But
the senior citizens can do this only if the
where-withal of a modest living is provi­
ded to them. Then older citizens become
elder citizens. They will wield a worthy
and healthy influence all around them. Only
then can they expect to receive the two
blessings of a happy evening and an easy
exit.
e

Ho

■i

14^
.

___

Principles of Exercise
for the Elderly
Bella J. Maya

Let me grow lovely, growing old
So many fine things do.
—Baker (1)

WHO ARE THE ELDERLY?
At 85, Barbara Garden is part of the fastest growing age group in the United
States today. She is a divorcee whojiyes alone in the suburbs of a large metro
politan city in the house she has lived in for the past 30 years. She walks 2 miles
daily, controls hypertension with medication and diet, complains of joint pain
from osteoarthritis, but is otherwise fh good health. She is active in the senior
center, although she complains of not having the energy she used to have.
Carol Sky. a widow, is 68 and has diabetes, hypertension, and degenerative
joint disease, particularly in the knees and hips. She hacHt total lelt knee
replacement about 3 months ago. She lives in a small house in a rural commu
nity not far from the farm where she raised her family. Her children, who live
in other parts of the state, visit regularly.
Both of these women function independently, but if injury or disease
should suddenly hospitalize either, how would they adapt?
Statistics indicate that the population is getting older and living longer. By
the year 2000, almost half the deaths in the United States will occur after the
age of 80 (2). An increasingly older population mak'-s more demands on health
services with individuals over 75 years as a group using more health care
resources than any other single group, but the elderly seek quality in their lives
and the opportunity to maintain good health as well as to functionally recover
from the loss of health.

°The author is indebted to colleagues Jancis K. Dennis, Maggie Cooper, and Osa Jackson
for their useful comments and suggestions during the development of the manuscript of
this chapter.
2-79

280/

Therapeutic Exercise

Cha

and psychosocial
years, while an ac
con.'.idcicd approp

(he person m poor health, functionally limited or with impaired intellectual
capabilities, may believe thatt most older people have difficulty functioning. Kvi
tek, Shaver, Blood et al. (3) in a study involving 127 physical therapists,
reported that therapists tend to set
set less
less aggressive
aggressive goals
for nlH^r
older individuals
goals fnr
than or younger patients with the same disability. They also found a positive
.•orrelauon between attitude toward the elderly as determined by a standardized
questionnaire and agressiveness of goal setting; therapists exhibiting a more
positive attitude set more aggressive goals. Actually, only about 5% of the older

The

ll™

I

i«

Researchers generally divide the elderly demographically into three
groups: the young-old (65-75), the old (75-85) and the old-old (85 + )
Research is increasing our knowledge of normal aging and our understanding
m uhol
n^ed:>.Lbut Schaie (4) ur8es caution, reminding us that many of the
methods used to assess elderly function are not designed for real life situations
and often do not consider motivation or emotional state, both important com
ponents to understanding elderly functiop.

I

Why a Special Chapter?
The reader may be wondering, “Wh/a'thapter on geriatrics^" I ife growth
and development are cycles, and humans do not function similarly in e"‘
phase. Just as the child presents with special problems and needs so does th<
cues are critical and how

total knee replacement will she be able
• 1 .She 5 hosPltahzed for a second
as speedily as the therapist expects’ Will the small Tom n"
Pro«ram
support services?
'
commumty provide adequate

PSYCHOMOTOR P

The aging pi
strength, and endi
indi\ iduals declin
are generally in lar
are attested more
by muscular limita
can learn fairly coi
cauti<jn in movenv
and respond to sti
a wider base of su|
if there is joint pa
elderly generally <
they can usually t
responsive to treat
Psychomotor
can occur as the cc
pai al lei to i ross iii
ol watci in the nut
discs. Decreased a
and strength.
Loss of muscl
including decrease
leading to decreai
may also be due to
changes in muscle
Postural changes r
as postmenopausa
tures. and pain.

SENSES AND PERC

.h« JLrzzz”'» zx

Vision is usu

descriptions for the well elderly as well as h
(- 9). The creativity and decisTmmTk ng
1

i n' (hrhl f

^trjy

Un
or group of clients .s t m best r t
'
e-xercises. This chapter will consider t n- < /
!
die older individual seeking rehabi/han
"Ctd*
with principles for effective decisio^m'^'^

fOGOn,/ j »(/! |

i"

f'

y Hi 4

bur du ii,'hvKlh,f) fft

or may be n

the well elderly

f

1 niuil(pie physical

COGN/nON

bhangs (n rin.
greatly, /n the absence

Chapter 14—Principles of Exercise for the Elderly
); our ow-n biases are
equently exposed to
mpaired intellectual
■ulty functioning. Kvi
physical uieiapists,
for older individuals
also found a positive
ted by a standardized
■ts exhibiting a more
ibotiT
of the older
ve independently in
aphically into three
the old old (85 + ).
d our understanding
g us that manv of the
or real life situations
'both important com

iatrics?" Life, growth
tn similarly in each
d needs, so does the
ilities, and the clini
guide the person to
environmental con
ility q
* differently
wears glasses. If she
?n she does not have
tot responsTve-* W hat
italized for a second
■he exercise program
ity provide adequate

of specific exercises
are manv exercise
loiogical conditions
‘rapist working with
specific therapeutic
the \\ell clde! lx and
■II prcwide clinicians

tttern of hinaion.'il
nological nui phys-th multiple physical

/281

and psychosocial problems may be considered physiologically closer to 65
years, while an active and healthy 65-year-old may run a marathon at a pace
considered appropriate for a 50-year-old.
PSYCHOMOTOR PERFORMANCE

The aging process inexorably brings changes in work capacity, muscle
strength, and endurance. It has been estimated that work capacity in sedentary
individuals declines about 30% between the ages of 30 and 70 (6). Decreases
are generally in large movement made at maximum speed, and routine activities
are affected more by a slowing of the reaction and decision-making time than
by muscular limitations themselves. Given time for motor planning, the elderly
can learn fairly complex movements. As individuals age, they may exhibit more
caution in movement to compensate for the increased time needed to interpret
and respond to stimuli Such changes may be evident as the person walks with
a wider base of support, takes shorter steps, and walks more slowly, particularly
if there is joint pain or muscle weakness secondary to disability. The healthv
elderly generally exhibit minimal gait changes; if marked changes are noted,
they can usually be related to some sort of pathological problem that may be
responsive to treatment.
Psychomotor performance may also be affected by loss of flexibility which
can occur as the collagen fibers of ligaments, tendons, and capsule change from
parallel to cross-linking. The spine also becomes less flexible secondary to loss
of water in the nucleus and changes in the fibrous annulus of the interveterbral
discs. Decreased activity is another contributing factor to loss of both flexibility
and strength.
«
Loss of muscle strength is usually due to a complex combination of factors
including decreased activity, decreased efficiency of the cardiovascular system,
leading to decreased circulation. Some general lassitude and loss of strength
may also be due to chemical factors, particularly lack of potassium secondary to
changes in muscle cell permeability. Loss of strength can also be due to disease.
Postural changes may be evident as an individual ages, particularly in women,
as postmenopausal decreases in bone density may lead to poor posture, frac­
tures, and pain.
SENSES AND PERCEPTION
Vision is usually one of the first senses affected by aging. Physiological
changes may lead to decreases in depth perception, reading ability, and visual
acuity. The client may have difficulty reading a home exercise program or see­
ing potential hazards in the environment. Decreases or loss of vision can limit
mobility and isolate the older person.
Decreases in auditory function may start as early as age 40, affecting thresh
olds for tone, speech, and pitch. Hearing aids may compensate for some loss,
but the individual may have difficulty differentiating between words with similar
sounds or may be unable to attend to one particular auditory’ stimulus when
surrounded by many different sounds, or if the stimuli come too fast. The older
individual may simply need more time between words or fewer surrounding
stimuli to discriminate between competing sounds.

COGNITION
Changes in memory, intellectual function, and learning ability vary
greatly. In the absence of disease, the older person undergoes little loss of intel

ililili
282/

.

Therapeutic Exercise
Chapin

f

life situations.

LIFE-STYLE

8

c” *» ■ sea. deter™.“>?SEoJ‘°“ °'

Disability does no
als recovering from con
benefits have been we
recruited individuals re
coronary rehabilitation j
under 62 years of age. Al
intensity. both groups
despite similar recruiting
ipate, as opposed to 59^
reasons for nonparticipa
ha\c been a problem.
Zinmaii and Vranic
1 ype 1 and Type II diabe
be encouraged to partici
benetits sull need to be <
temia. but may induce v
monitor Ins own blood
accordingly
It k suggested that r
ital function. Although ca
there have been statistics
jects who participated in
sedentary liie-sty'le both in
seem to agree that individ
ticipation in regular exerci
among the impaired eider

”d

benefits of exercises
Preventive Measures

e

Ix-tX"

MeZr n

^"V01 8r°Up' Sinaki “d OfFord (2 )
lg

°f back extensor muscles an^h

c<mu\>| group Thecv
group cxcici>ing with
tiler appeared to have
who had reported som
joint pain at the end, i
cated any increase as a
exercise groups showe
flexion, shoulder flexio
with the control group,
icant improvement in s
ing with weights.

Whi,e “ decreased by

3 P°Sitive reJationship

WELL
<M «88yr'j.s'i 10. 25Tfc’

ihree groups otelderly W(

Western society is bee
older individuals still com
the younger generation. Ot
know where to start or how
their individual needs. Still
grams or arc afraid that ex
changing, as is evidenced
water aerobic classes, exerc
enterprise?..

otatatfckll„.. jfcj

i

Chapter 14—Principles of Exercise for the Elderly
haie (4), in a ' year
of HO showed relioughout life, elderly
fast, and may exhibit
(4) emphasizes that
for an older popula1 may not reflect real

^vision news special,
■om disease or debiliy clients may have
. and feel the loneli
japtability decreases
been found to func
>le to maintain them
>ecome quite de pen
' stvie changes arc a
by loss of abditv and
on.

• declines ot normal
re and well designed
•und
’ecline with
len results were nor
Han’t!rd alumni, sed
cardiovascular death
d an even lower risk
>s in postmenopausal
mineralization in 31
n of the lumbar spine
vhile it decreased by
positive relationship
neralization. Brewer,
activity on bone min
ed that runners main■their more sedentary
jps of eld'-: h " < ’men
)osed of women who
months One experi
light v.eights ■.m the
rd the c\ck is< s u uh
ps showed Mgnihcant
as compared \x idi the

/283

control group. There were no statistically significant differences between the
group exercising with and without weights. Participation in light exercises fur
ther appeared to have a positive influence on joint pain. Seventeen individuals
who had reported some joint pain at the onset of the study reported decreased
joint pain at the end, 10 indicated no change in joint pain, and only two indi­
cated any increase as a result of the exercises. Similarly, participants in the two
exercise groups showed significant improvements in flexibility in ankle plantar
flexion, shoulder flexion, shoulder abduction, and left neck rotation compared
with the control group. The group exercising without weights showed a signif
icant improvement in shoulder abduction as compared with the group exercis­
ing with weights.

Patients with Disabilities
Disability does not appear to be a deterrent to exercising. Many individu­
als recovering from coronary disease participate in exercise programs and the
benefits have been well documented. Ades, Hanson, Gunther et al (25)
recruited individuals recovering from myocardial infarction for a supervised
coronary' rehabilitation program. Participants were divided into those over and
under 62 years of age. Although the older group achieved a lower peak exercise
Intensity, both groups obtained similar relative training benefits However,
despite similar recruiting efforts, only 19% of the older patients chose to partic­
ipate, as opposed to 59% of the younger ones. The authors did not analyze the
reasons lor nonparticipation, but conjectured that multiple disabilities might
have been a problem.
Zinman and Vranic (26) studied the effects of exercise on individuals with
Type I and Type II diabetes. They recommended that individuals with diabetes
be encouraged to participate in an exercise program, although the long term
benefits still need to be establi.<hed. Exercises improve postprandial hypergly
cemia, but may induce delayed hypoglycemia. The diabetic client needs to
monitor his own blood glucose level and adjust both insulin and diet
accordingly.
It is suggested that regular exercise improves intellectual and psycholog­
ical function. Although caution is advocated in interpreting results of research,
there have been statistically significant improvements in function among sub
jects who participated in a regular program of exercises and those who led a
sedentary life-style both in and out of institutions (3, 27). Generally, researchers
seem to agree that individuals with physical impairments can benefit from par
ticipation in regular exercises and that more research on the long term benefits
among the impaired elderly is needed (17, 28, 29).

WELLNESS EXERCISE PROGRAMS
Western society is becoming more health- and fitness-conscious, but many
older individuals still consider physical exercise and activities something for
the younger generation. Others want to maintain an active life style, but do not
know where to start or how to adapt the commonly available activities to meet
their individual needs. Still others with some disability cannot find suitable pro
grams or are afraid that exercise will exacerbate the disability. Attitudes are
changing, as is evidenced by the Increasing number of mall walking groups,
water aerobic classes, exercise videos for the elderly, and similar commrn lai
enterprises.

284/

Therapeutic Exercise
Assessment of the Well Elderly

lhe initial history includes a list of medications, a life-style inventory to
ermine current activity level, gross assessment of strength flexibility coor
d nation and balance. There is some diversity of opinion regarding tl7e need
for specific stress testing before the well elderly engage in a fitZ pro Jam
most authors, however, advocate some determination of cardiovascular capacity
o establish starting heart rate guidelines (10, 30-33). Standardized stress tesj

UoTZiS^Z-r6 HUitab*e f°r the eldMly individu;11

• Smith
and
umigan (
described a modified step-stair test where a sitting client
raised
one loot up to a step of a particular height over a specific time period Cuid
stepsPr°Vided f°r determinin8 MET levels for se^ral different height
Components of a Wellness Program

A wellness program includes activities designed to improve strength
enXvlbl ‘lt?^ll*ty.’-pro"lote endurance, improve balance and coordination be
ij >>abk, and fit into the person’s life-style. May (34) reported on a series of
w'n'/‘S deS'8"ed f0r an Elderh°s'el camp which incorporated educational as
ell as .utivity sessions and were designedho enable the participants to make
cHtcine decisions when making life-style changes.

ill

Of
’rd

fl

STRENGTHENING ACTIVITIES

well I XerClf>e.tor lhe uPPer and lower bo,dy as well as the trunk are part of a
designed strengthening program. Active exercises, the use of free weights
and exercise equipment such as are available in health spas or fitness centers
can all be used by elderly individuals, both men and women. Proper instruc
lions are necessary to prevent injuries.
mstruc
Major muscle groups need to be included with the weight selected to
a ow iom io to 12 repetitions through the full range of motion' The trunk and
bel Xe h y ar|C‘.lretiuent|y overlooked by the elderly; Barbara Garden may
believe her walking program meets all of her fitness needs. The particular tvoe
of exercise needs to be selected according to personal preLJnce Man ■
w01«cn lor example, may not care to exercise in the free weight section of
health facilities, but would participate in low impact or water aerobic programs
Trunk exercises need to emphasize good posture but must consider individual
variations in posture which may not be amenable to change.

in (enns of balance
ha ms i lings.
Occasionally,;
in one chair raising
back straight and re
hip tlcxor and recti
and lyiIji’.,-.' Self st
stand npnghi hold!
enough to provide t

FLEXIBILITY ACTIVITIES

Functional pursuits may be limited by lack of flexibility in major joints
ba‘ck oTTh " l'nJXfind " d'ffiCUlt tO reaCh somethin8 in the cupboard, comb the
Lack of the head, or even put on shoes and socks. Another with limited tlexi
bihty may not be able to respond to a sudden change of position or loss of
b«lan«. »=x,b,U1y aeuvlte, „e ■>„ ™SI forgo„en pan „(’eltae“"p“
Generally, individuals need to increase shoulder, trunk, and hip flexibility
particularly in extension and rotation ranges. Shoulder range of motion and
uj per trunk extension can be improved and maintained fairly effectively using
loinbin.Hion nKWcnienis and a .small lowel (I;ig. 14.1).
The older client needs to be taught a safe, effective, and simple technioue
io stretch hamstrings and call muscles. Long-sitting is probably the safest way,
Figure 1

*-n-

Chapter 14—Principles of Exercise for the Elderly
Figure 14.1
flexibility.

ife-style inventon- to
gth, flexibility. coorregarding the need
n a fitness program;
"diovascular capacity
dardized stress testidividuaL Smith and
sitting client raised
ime ■
od. Guideral dinerent height

/285

Increasing shoulder

7)

improve strength,
id coordination, be
irted on a series of
ated educational as
articipants to make

trunk are part of a
ise of free weights.
> or fitness centers
*n. Proper instruc-

/eight selected to
on. T
rur.k and
'bara Garden may
he particular type
^reference. Many
weight section of
lerobic programs,
■nsider individual

f-A >•>'

f-f'J

i

in terms of balance, but the client may stretch the low back more than the
hamstrings.
Occasionally, an older person finds getting to the floor difficult and can sit
in one chair raising the feet on a small stool or other chair while keeping the
back straight and reaching for the toes (Fig. 14.2). Manv older individuals have
hip flexor and rectus femoris tightness which can interfere with good posture
and balance. Self-stretch for these areas is difficult. One practical method is to
stand upright holding to a chair or other support, one leg behind the other far
enough to provide some range into’hip extension (Fig. 14.3).

; in major joints,
'board, comb the
ith limited flexi•sition or loss of
’Uness programs,
id hip flexibility.
.* of motion and
effectively using
imple technique
y the S3les| \\ ;|y
Figure 14.2

Stretching the hamstrings In a balanced position.

286/

I’herapeutic Exercise

Figure 14.3
chair.

Stretching the hip flexors using

Of

'^1
A

k

W^''
S'
.a <■- t
j®.

Wf

®

■KSr

,

a==S=sSS=B®s

examples might include.-

I

-

trunk and pelvic
i area individually. Some

I siren lung both arm.s 1(, lhc ccj|jng [hen bending gent

1

t()

with knees
knees flexed
flexed and arms at side, aHowing\iic
3.3 Lying ™„
on the
(he baX'
back with

L
&

>< S rm the light side, rhe motion is then repeated in reverse to return
st ir iiJ’u /‘"I ‘hen tO the °ther S'de' The Same :lctivity “« be done

/hv.' •-<.>■j.

x

™.

SSe’ZXkXTS1 aT"? "“ MCh '"'•Vli

............................................ ■■"- ‘l““

< .j' j^'ia

fl

.•j; &» • ^‘■^.. i.nu.:.

■I fe

Figure 14.4

o

Trunk mobility oynrclco

W5WW.

w ft

BH

Wi
’’'’f

Figure 14.5 Combined mobility exercise
tor hips, fmnk, and shoulders

■

trunk flexibilio and
id peb • - movements
a ind. .u.ilh. ''ome

th to each side:
shoulder height
?lders, letting the
>n (Fig. 14.4 );
de, allowing the
=mple), following
arm up rwer the
■< until the head
and the person
reverse to return
Jity can be done
ollow when the

’ that teach the c!i
tnce smooth coor
ody moves and be

V..-

V ''7' i^r^X

i

;r

■E .

B
i

r

i.v', a

287

288/

Therapeutic Exercise

Ch*

encouraged to allow the body to move easily in performing flexibility move
ments. General guidelines for teaching flexibility include:

with each str
and rolling <
long a step.
5. Walk coatin’
training effe<
6. Galkin aniisame time e
7. Whenwalkiithe stride a
8. Start slowly,
imurns are
motivation.
9. Cool down
block or tw<

1. Start in a comfortable position;
2. Move slowly to the end of the range;
3. Hold at the end range for 10-20 seconds;
4. Feel a gentle pull or stretch, but no joint pain;
5. Return slowly to the starting position;
6. Use slow coordinated active motions involving varied body movements•?
Repeal 3-5 times.
AEROBICS
Aerobic exercise programs are primarily designed to improve cardiorespi­
ratory function, although many include flexibility and strengthening activities
I he level of resting heart rate increase necessary to achieve a training effect
among older people has been the subject of considerable research. Badenhop
(55; reported changes in VOZ max at a .50 15% increase in resting heart rate
among volunteers over 60 years of age. But Lampman (32) recommended a tar
get heart rate of 65 75% of maximum, anti Smith and Gilligan (10) recom
mended targets of 40-70%.
Most researchers do agree that the elderly individual should start slowlv
butld mtensity gradually and that IndM'duality Is needed in establishing
atgei heart rates. It is important lor the elderly to understand the difference
between low mtensity activities that accompany an active life style and aerobic
acuviiies. Many people who to
respond
. questionnaires
............
life style
indicate that
they garden, do housework, and stroll on the beach as part of their exercise
program. Unless the program is designed to increase
heart1 rate, it will not have
-------- -----the desired training effect.
Among the wide array of aerobic opportunities are: high and low impact
classes, water exercises, exerdance classes, mini trampoline programs swim
ming laps, riding exercise bicycles, or using computerized rowing machines
some sport activities provide aerobic training if continuous movements are
involved. Water aerobics lessen stress on joints, but participants, particularly
women, need to include some weightbearing activities as part of a management
program for osteoporosis.
6

Overall time

i. Ik- safe inti
2 Be designe*
klmamHi, ba
3. lk‘ at an int
i Include a v
cool down 1
s. Allow partk
6 Give partici
what sensat
7. Be perform 1
8 Be perform
and,
9. l it within tl
tency of pat

In addition,
a comfortable en
of heat or air con
may have difficu
music frequently

WALKING
One of the more jpopular
t ’ activities is walking. Recommendations for an
effective walking program include:

co«

1.

Wear well fitting lace-type shoes which provide good support and
shock absorbtion; wear thick socks that will absorb perspiration and
protect the feet.
2. Wear comfortable, loose-fitting clothing appropriate to the temperature
and weather.
3. Walk at a rate designed to bring the heart rate to target levels; 3 to 3.5
MPH may be a good training pace for the average person.
> Walk in an easy balanced position, head upright, looking ahead rather
than directly at the ground, arms swinging easily with each stride, using
a slight pushoff step with the rear foot and leaning forward just slightly

■?

The elderly
include dysfunct
nition The clien
may be altered b
significant others
tei n of soculizat
ber of society, c
There are also ec

ti

Chapter 14—Principles of Exercise for the Elderly
lexibiliw move

■ move' ^nts:

?ve cardiorespi“ning activities,
i training effect
arch. Baden hop
sting heart rate
mmended a tar
an (10) recomuld start slowly
in establishing
■1 the difference
vie and aerobic
?s indicate that
!f their exen ise
it will not have

and k unpact
rograms. swim
ving machines,
movements are
its, particularly
a management

ndations for an

/289

with each step. Take long easy steps from the hip, landing on the heel
and rolling over the foot in a smooth motion. Avoid reaching for too
long a step.
5. Walk continuously, frequent stops and starts interfere with the aerobic
training effect.
6. Walk in an interesting area at a suitable time of day. Try to set aside the
same time each day for the walk. Walk with others, if desired.
When walking up or down steep, hills, lean forward slightly and shorten
the stride a bit to maintain a balanced pace.
8. Start slowly, but gradually increase distance and time until desired max
imums are achieved. Keeping a log of accomplishments enhances
motivation.
9. Cool down with a flexibility program, a slower paced walk for another
block or two, or some gentle conditioning exercises.

General Guidelines
Overall fitness programs for the well elderly must:
1. Be safe in that the potential for injury is minimized;
2. Be designed to improve muscle strength, flexibility, endurance, coor­
dination, balance, and functional capabilities;
3. Be at an intensity level to provide a training effect;
4. Include a variety of slow and fast activities including a warm up and
cool down period;
5. Allow participants to lower the level of participation, if desired,
6. Give participants an understanding of the purpose of the exercise and
what sensations may be elicited;
7. Be performed regularly, atTe^st 3-5 times per week;
8. Be performed for at least 30 minutes and preferably 1 hour each lime;
and,
►
9. Fit within the life-style and interests of the client to encourage consis­
tency of participation over lime.

In addition, aerobic programs should be of low impact and performed in
a comfortable environment with a shock-absorbing floor, at appropriate levels
of heat or air conditioning, and at a reasonable sound level. Elderly individuals
may have difficulty discerning oral instructions above the loud noise of fast
music frequently played as part of aerobic programs.

CONCEPTS OF EXERCISES FOR REHABILITATION
support and
piration and

tempera lure
vels; 3 to 3.5

ahead rather
stride, using
n just slightiv

Assessment of Function
The elderly client usually presents with multiple problems which may
include dysfunctions of motor control, of sensorium, of perception, and cog
nition. The client comes with certain expectations, fears, and a body image that
may be altered by the aging process or the disability. There may or mav not be
significant others in the environment, but the individual has an established pat
tern of socialization, a broad background of experiences as a meaningful mem
her of society, certain Interests and hobbies, and an established personality.
There are also economic factors that may also affect the client's ability to panic

u

290/

Therapeutic Exercise

Chaj:

ipate in the therapeutic program. Additionally, there is a physical environmen.
el,?.'?!1 Ile .ncpl|1ISI "Ulst fun<-'t‘on, an environment with time pressures
expectations ol others, as well as rules and regulations
Pressures,
I he assessment is a broad based determination of the client's current level

stood instructions o
to adapt and respor
build a sense oi trm
environment requir
Motivation car
or act in a particular
of any therapeutic ;
any different from b
between the goals
which that individt

~
evaluation. How valuable is it for the therapist to know that Barbara walked
2 miles a day and that
Carol1 was fairly sedentary?
--------GROSS ASSESSMENT

avail/kTLrT'T1'”1 111 ,,,,>lOr t0nlro1 illtluding coordination of
movement,
•natioti leShg s^XPr0Vide

be the M.uc.c.g.,C

I
with the young old

M

° c oia n comparison

e„.w.°d“SX'lTZup”^

expend

detenorauon of strength, posture, and limitation in joint'modoi/1' ’ ,nCrea5ed
FUNCTIONAL ASSESSMENT

r ? de‘cie“i“-ihere “

-d.™

!

I

I

and adjust to the therapeutic environment.

t0 ada»’1

Y

Motivation and Adaption

eeide™

than with the stren
Two types of
motivation, that wl
motivation that w’
internal dialogue (
positive or negativ
that r.ne will not b
may use self-talk tc
Jackson (36)
Critical to the proc
gi\ lag the patient
importance of the
mem to promote a
directed in the th*
suggests asking tht
lifying the skills si
decision making.

“‘''IT'’' b“ ““ “

the .‘ *"

sonal habits, the many/ unknown people, confusing activities, not clearly under-

Barbara Gard
is not responding
the therapist repea
therapist, shouting
into her face. Fami
responding client:
mismatch between
merh- id of learning
body movements—
more preferred m<
terns and linking r
To use new f
information must I
communication te<
ci lie eft oris are mac
is used as a link tc
ticular tone of vol
emotional or phys
object translates ar
For the elder

Chapter 14

i physical envircument
t with, time pressures,
le client's current level
»otenti-d foi '•mctional
mation hut it is not the
ow that B idvr? " dked

dinat
of movement,
abilities provide inf’orvention. Assessment of
onal activities. Keep in
a the elderly is smaller
old-old in comparison

I

■ition on movement dif
d difficulties with func

does not straighten at
walk, get up and down
ing are closeIv interreinterfere with the nor
ploting alreadx limited
activity with increased
■t motion

•f defi
tcies. There is
ormance of successful
on moves, current posiring movement and at
ses to instructions. The
st individuals strive for
■ssihle. t or the individ
:lity to get in and out of
rea or social room. For
participation in sports
>nents of function, such
roader life style, which
’sical aspects. The ben
client s ability kj adapt

rydMdint^ ho,t
<ta of injury or disease,
of usual lifelong per
dies, not clearlv under

Principles of Exercise for the Elderly

/291

j'P'-uc.kms or information all impinge on the client and aHe.a the ahilitv
I >ild
e1’ 1'7P‘>'Kl. appropriately. Part of the therapeutic intervention is
env rr,
Of T between the therapist and the client and to provide a safe
n tronment requiring as little adaption as possible
Motivation can be defined as the need or desire to achieve a particular goal
act In a particular manner. Motivation is a necessary ingredient in the success
o^arp- therapeutic activity, fs helping the elderly client to became motivated
any different from helpmg younger clients to do so? The degree of congrm-nee
between the goals ol the therapist and the diem is rellect’ed H, the extent io
be the same'e
c'al
‘0
motivated' The
may not alwavs
e the same, e.g., Carol might be concerned with the steps into her home rather
tan with the strength of her knee, and she may not relate the two
Two types of motivation are Recognized: internal and external External
motivation, that which is provided by another, is temporary in nature internal
mot.vat.on, that which is provided by the person, and is often reLeted n
internal dialogue or self-talk, is the one that lasts. Internal moth .lion can i'e
positive or negative. Carol Sky may use negative self talk to convince herself
hat she will not be able to manage the steps at home, while Barbara Garden
may use self-talk to overcome her fear of walking again.
Jackson (36) identified a six step approach to the unmotivated patient
Critical to the process is building trust between the clinician and the patient
gmng the patient time to share individual concerns, and recogniz ng the
importance of the client’s goals. Jackson believes that creating a sab'environ

;Ztedr
sense °[seprocess
"w,,r,hare
:,n(iImportant
he,pin« t,’for(- motivation lewis (371
:f
diterted in he7
therapeutic
suggests asking the patient to select the best time of day for treatment' and'iden

"k" “ dev'"” “

’"'"'’-r th.- ...... ...... .

Communications
Barbara Garden, sitting in a Wheelchair in a busy physical theranv clinic

i

bor d of ,earning- Much of therapeutic exercise consists of teaching particular
body movements-some simple, some quite complex. Individuals h we one o

tern7rn
rd HXrn^S ,"Offf°tranSlaUn8
SenSOry information
meaningful pat
To1.se S L
rmat,on with alr«dy existing data in memory.
To use new knowledge or perform new movements, new instructions or
commm 0"."1115' 7 l,nked tO Somethin8 known Dickinson (38) described a
communication technique known as neurolinguistic programming where sne
use^
Tl13
tO)find eXiSting anchorS
a client’s^eX Th^nXr
used as a link to teach new information Everyone has manv anchor, a .

I or the elderly client who may have decreased auditory or visual capahi I

292/

Therapeutic Exercise

process, can often indicate preferred ways of learning Xend
Barbara might have said to he theranist /In h
.

enviXmJnVthSitXm'VSe
strange instructions If the oldi Pf

t0 h""

Wonunity,

SklHS in 3 Safe and c<uleI

d'° adapt quickly to "^’siiuations and

sU he „

I

because 1. is
lor ,he d,e„,

O
apl«“2vo '«
«>«""«>
and ”
an “
<.......
■

effecilve ihmpeuUc exereises »i,l, .h“”lded,

“«r'di“'! '«
important 1ingredients
for

Facilitating Breathing

*id»uK>1's:snx±;'™«Te,ne”“ ■“

Although Carol Sky does
Of our Clients may be found o h. v
the breath when attempting movement
breathing. Reoetitivr exprri^c
,.,;n ~.
respl,^,,^,,,
““ -

reuSPiratory disease, she, like many
h°ld
awareness ol her own

breathing and
movement anc

Movemer
assessment thaachieve desire
cional movemt
Young old ind
in an active lif
exercoe ma chi­
gene rally respc
pr’oceptive ne'
lunctional mov
either weightsb
Another is sitt
gradually onto
the arms forwt
Combining knt
resistance at ap
extremity tunct
It is impor
functional mov<
raihei than with
should be pie;
learned more e
energy-efficient
Vildman (42) j

S1„„.
there much excursion of the thonr \ h
respiralory movements? Is
matic breathing? Does the client
Cr|eSt Wa ' IS -here evidence diaphrag
because of difficulty in breathinn? oh01 SO|Ue positlon’ such as prone-lying,

-egubr, ta slow. nS“Ke°„S !*

/M-. ■« «

absence ol depressed affect is a forced hyI il° time? Slghin^’ in the
mhalatton and is a sign ol poor ventilationa'10" CeS‘Kned tO Provide deeP^r
< ise Jn/r nn1 c?’ i* ‘O ,aCilil:'te ■5clf awareness. At different limes in the exer

h

twXXZXnttr a”" deSCribe

b-ad^

H"
>>lwiv<x Huldinu it
11118 ca1} make movement easier.
I,,‘IS Ich. Movement and breathing cm h
1,18 where and h°w the
movements the client can perform easily and bt f‘nte8rat1ed stanm^ wtih small
difficult movements. If Carol becomes short of h ' "Z “
m°l'e conlPiex and
io break up more difficult tasks into more easilJ/m ^ki7’ She Can be tau8ht
simple specific respiratory exercises described fn
Fr«lue'1tly,
.................. ...... .........

FwOwfe- S’

Chapter 14—Principles of Exercise for the Elderly

. Therapists are
r in the learning
he opportunity,
my hearing aid,
nd what you are
a safe and quiet
w situations and
h the expected
ited.” Yet older
g,ve'
ne and
Hy (3
s before
a: a '
n
ling rhe equipch or by asking
Client feedback
o you have any
take of the head
is a commodity
exploration and
an opportunity
ingredients for

ly interrelated.
, she. like many
'ndcncy to hold
ess of ’ -r own
>reath...n, since
)1.
ipiratory status,
movements? Is
ice of diaphrag
as prone lying,
m: is it regular.
Sighing, in the
provide deeper
nes in the exer
her breathing,
wement easier,
e and how the
=rting wtih small
re complex and
e can be taught
rts. Frequently,
hapter. <.ui i»e
’e the quality of

/293

breathing and help the client learn how more effective breathing can improve
movement and reduce fatigue.

Facilitating Movement
Movement can be facilitated in a number of ways based on individual
assessment that guides the therapist in the selection of appropriate patterns to
achieve desired goals. Generally, elderly individuals respond better to func­
tional movement patterns rather than specific muscle strengthening exercises
■Young-old individuals with single pathological problems who have participated
in an active life-style may well benefit from the use of sophisticated isokinetic
exercise machines. However, older people with multiple movement problems
generally respond better to manual exercises or self-directed movements Pro­
prioceptive neuromuscular techniques can be quite effective as is the use of
functional movements as exercises. For example, one natural sequence mav be
either weightshifting sitting, then standing to learn hip and trunk patterns.
Another is sitting-to-standing activities, emphasizing forward weightshifting
gradually onto the feet by bringing the head and shoulders and, if necessary,
the arms forward until standing becomes a “natural sequellae (Fig. 14.6).’’
Combining knee flexion and extension with ankle motion, providing manual
resistance at appropriate points, can facilitate the feeling of coordinated lower
extremity function.
It is important for the client to participate in the exercises bv learning how
functional movements feel and allowing the body to move smoothly and easily
rather'han wlth excessive effort. Felderkrais (40) emphasized that' movement
should be pleasurable, as pleasurable movements relax respiration and are
learned more easily. He advocated that movements should be light, easy and
w fd8'
Wheniteachinff Felderkrais movements, both Jackson (41) and
Wildman (42) stress that motor learning must be slow and comfortable, that

Figure 14.6

Slt-to-stand exercise.

294/

Therapeutic Exercise

Cha^

fatigue, strain, or pain interfere with learning, and that new efficient and easy
movement patterns will gradually substitute for older, less efficient patterns as
the client develops body awareness. Rhythmic activities with slow reversal pat
terns can also enhance coordinated movement.
Imagery is another useful tool, the client being asked to remember the
eehng ot normal motion and to try duplicating it. Movements of an unimpaired
extremity reinforces an image; or, the client’s past experiences can guide the
selection of appropriate images. Breaking a complex skill down into small steps
will also make it easier to learn.
I here are key words such as: "easy movement,” "allow the body to . . .
feel light, how can you make the movement as effortless as possible'-1” which
may communicate the therapeutic intent. Feedback, given in a positive and sup­
porting manner, must be accurate, clear, and directly related to what is being
learned. It ls important lor the client to feel safe from possible fall or injury
Asking an anxious patient what would help him feel more secure may provide
useful inionnaticin.
r

Exercising in
nuiiy There is [he
pendently. using r
exrreT Ty ■ aovemei
. .. .;:i J wail:

Hie trail elder
abiluy that interfer
support for daily ft
ing adult day care
participate in regu
eral opinion, the
designed exercise
e.\erci>es designed
ous wellness and ti
ronments, and Chri
be performed sittii
Practice in f
enhances trunk fie
Most upper extren
formed by the frail
or. if standing is p«
(Fig. la.7 and 14.8
rarely a problem, b

Treatment Environments
The therapy department in a hospital or rehabilitation center represents a
sale but closed environment. The client learns to move and function under
yy-ii'y and with supervision. There art? parallel bars for gait training, the mat
table ls bioad the therapist uses a safety bell, and there are no sudden move
ments from others to startle the client. The closed environment is predictable
and does not ref ect the real world the patient is preparing to reenter. Elderly
c tents must not be discharged from the hospital or rehabilitation center unpre
pared lot adjustment to the more open environment of the home situation ft is
thus important to teach transfers from surfaces of different height Gait training
on tarpias and uneven surfaces, with people moving around, provides practice
io help cope with a more open environment.
Often, Medicare regulations may mitigate against giving individuals both
the tune to develoj, sell i onlulence tn their abilily to function and the time to
work eilectively wtth sigmHca.u others who may provide key support in the Iran
sition. All of these factors increase the need (a) for the client to be actively
involved in establishing goals and determining how best to resume prior func

ZX

T

“vi,“10

Home health care has been established to serve as the bridge between
hospital and home living. Where available, the home health therapist has the
unique opportunity to work with the client in the familiar but more open envi­
ronment of the home. Here the bed maybe too low, the bathroom entrance too
small, the bathtub without rails or seats, and the kitchen unusable by someone
using a walker. There may be scatter rugs, a dog or cat, or telephone cords on
h
C ‘ent 8°eS outs,de’ there are jostling people, fast street lights
and limited transportation, rhe home health care therapist needs to assess the
home situation and work with the client in meeting the most pressing needs
difficukv^^
r 8° “r
fbathroom alone usin« a walk«, but may have
difficulty getting food from the refrigerator to the stove and then to the table to
eat the meals her neighbor brings in. The home health therapist needs to be
aware of community resources available in each situation and to make appropnaie referrals.
1 1

—

Chapter 14—Principles of Exercise for the Elderly

iv efficient and easv
efficient patterns as
h slow reversal pat
d to remember the
ts of an unimpaired
nces can guide the
•wn into small steps

the ’—'dy to . . .
is po:
le?” which
a positive and sup
d to what <s being
sible fa 1.1 or iniury.
ecure may provide

renter represents a
id function under
it training, the mat
no sudden movelent is predictable
o reenter. Elderlv
lion center unpreime situation. It is
ight. Gait training
provides practice

/295

Exercising in the home setting requires considerable creativity and inge
nutty. There ts the challenge to design programs the client can < arry out inde
pendently, using readily available materials such as cans of food'for upper
extremity movements, belts and elastic bands for both upper and lower limb
exercises, and walls or doors as support for standing activities.

THE FRAIL ELDERLY
The frail elderly are generally those individuals with some permanent dis
ability that interferes with full normal function. They may need considerable
support for daily function, and may be in retirement or nursing homes attend
mg adult day care centers or living independently, but nevertheless unable to
participate in regular wellness programs because of di.sabilitv. Contrary to een
eral opinion, the frail elderly can benefit from participation in properly
c esigned exercise programs and can improve function through therapeutic
exercises designed to meet individual capabilities. Hurley (8) outlined numer
ous wellness and fitness activities for groups and individuals in sheltered environments, and Chrisman (6) describes and illustrates adapted activities that can
be performed sitting and with some external support
Practice in finding and maintaining a well balanced sitting posture
enhances trunk flexibility and strengthening as well as improving breathing
lost upper extremity and trunk movements mentioned earlier can be per
“TAtand'”
dmly'
'0Wer extremit>' zeroises can be done sitdng
H-iv u "
SP°S%. e’ LChair °r Wa'ker may be used to
^ance
.. '8. 1
.n.d 14;8)- The elder|y tend to be rather cautious, so overactivitv is
rarely a problem, but proper safeguards must be employed.
Figure 14.7

-? indh idiia Is both
n and the time to
ipport in the tran
?nt io he activelv
?sume prior func­
opportuni ties for
* bridge between
therapist has the
more open envi□om entrance too
:able bv someone
ephone cords on
fast street lights,
*eds to assess the
t pressing needs.
:er, but may have
en to the (able io
■ipist needs to he
i to make appro
t

Exercising with a chair for balance.

296/

<-■

Therapeutic Exercise

Figure 14.8

C

Sitting exercise.

1

In the group setting, staff are needed to safeguard individuals with poor
balance, to provide kinesthetic cues for the visually impaired, or visual cues for
the hearing impaired. A therapeutic activity program in a sheltered environment
helps clients maintain and improve on gains made during therapy. Such pro­
grams provide outlets for physical and creative energy and emphasize the ben
efns of being well rather than being sick. Group exercises that involve a number
of people, such as passing a ball around a circle on a sheet held by all partici­
pants, provide opportunities for social interaction as well. Internal motivation
is a critical factor, as the individual who values activity will maintain participa­
tion and benefit physically, socially, and emotionally.

SUMMARY
Guidelines for developing exercise programs for elderly individuals have
been provided. It is important to remember that the elderly are individuals with
a zest for living and a desire to participate as fully as possible. In the words of
Robert Browning (43):
Grow old along with me!
The best is yet to be,
The last of life, for which the first was made.

References
i.

2.

3.

Biegei u rnySl
: Rock*
ers. inc . 1984’
Cnrisman DC:
6.
Be e a Colleg*
Flatten K. Wi
7.
l xeicise Acti
York, Springe
Hailey O. Salt
a.
the Frail Eide
York, Center
1988.
Lewis CB, Fer
9.
cue Booklet.
it r$, Inc , 1
10. Smith EL, Gilpresefiption
Physician an
101, 1983.
11. Amanson A.
training in ol*
ence to qur
and morphol
1981
12. Grimby G: Pt"
tiaming in
Scand Suppl
13. Moritani T:
muscles of c
face RC (e<
Sports Medi
The Scientifa

5.

Baker KW: Let me grow lovely. In Lyell
RG (ed). Middle Age. Old Age. New
York. Harcourt Brace Jovanovich,
1980. p 379
lirniras PS: Physiological Basis of Geri­
atrics. New York, Macmillan. 1988.
Kvitek, SDB, Shaver BJ, Blood H, et al:

4.

Age bias: physical therapists and older
patients. J Gerontol41:706-709, 1986.
Schaie KW: Aging and human perfor­
mance. In Riley MW, Matarazzo JO.
Baum A (eds): The Aging Dimension.
Hillsdale, N.J Lawrence Erlbaum Asso­
ciates, 1987.

> WL

14.

T
M

I iGl IQ
O
I ikJj

C
a

Rechmtzer F
the training
Med Sci Spc
^aenv KH,
15
ana mtensit
eiaeriy sut
10:125-131
16. SiP ey KH. I
submaximur
women in
ninth decat
43 280-287.
17. Gorman Kb.
exercise in
4 181-192,
ia. Fleg JL. Lal
mass is
t
age-re!atec
oic capa
lli)72 464, 1‘
19. Pqffenbargt
ai. Physical
and lar.gev
J Mea314.<
20. Krolner BE. 1
icai exerci.

I

MANJIT MAHANTA

HITESWAR SAIKIA

“We will
crackdown”
WITH the ULI'A menace looming
larger than ever before, Special Cor­
respondent v ARZAND
AHMED

Spoke

tO

Chief
Minister
Hiteswar Saikia at
his Janata Bhavan
office. Excerpts:
4-

i

■a?
ULF A cadres: mounting menace

his murder: either ulfa suspected he
had come too close to Saikia or he may
have lost their trust.
"> <"AHANTA’S neighbour—con|% /I sidered to be an ulfa
_L V JL sympathiser—thinks it might
bethehandiworkofJatiyaMukti Bahini,
an organisation said to have been
floated with Saikia’s approval to counter
ulfa. Recently, ulfa publicly passed the
buck to the Bahini for crimes it was being
held responsible for. Whatever the rea­
son, an important channel for negotia­
tions has been lost, ulfa, anyway,
seemed extra chary ofdiscussions: to the
extent that it recently issued a public
denial of reports of such a possibility.
Negotiations with the Government, it
said, would be held only on the funda­
mental issue of sovereignty.
But this is not the only front on
which Saikia is being bombarded. His
failure to tackle the intractable mili­
tancy problem has created doubts in the
mind of the Central leadership about his
ability to govern. He, however, dis­
misses the suggestion as “mere gossip”.
If Saikia has bungled, ulfa has not
been any smarter. After coming under
pressure from the army, ulfa declared a
ceasefire and apologised to the people at
the end of February this year. It had
counted on a people's movement build­
ing up against the army’s deployment
but the Assamese seemed to welcome it.
Thinking the AGP might return to power,
it allowed peaceful elections, not having
bargained for a split in the party and a
Congress(I) come-back. With Saikia—
long-time foe—in the saddle, there was.

HOW IT HAPPENED
AUGUST 8: August 27 fixed as
date for freeing of ULFA captives.
AUGUST 27: Saikia agrees to
only an equal exchange.
AUGUST 29: ULFA demands 14
men for Paul and Raju.
SEPTEMBER 3: Adds four names.
Saikia calls it absurd.
SEPTEMBER 5: ULFA threatens
to kill hostages.
SEPTEMBER 7-8: ULFA kills Raju
and Bipul Mahanta.

therefore, only one option for the mili­
tants. To strike at the heart of a promise
of restoring peace.
And instead of standing firm from
the very beginning, Saikia allowed him­
self to be bullied and the ulfa stock to
swell by conceding one demand after
another. Also, as an army officer puts
it. the Government compounded its er­
ror by withdrawing Operation Bajrang
just when it had started getting public
support in a big way.
According to Saikia, however, the
problem requires delicate handling be­
cause at least 500 ulfa activists were
inducted into the police force at the
thana level while there are a large
number of sympathisers lower down. By
offering to resign, as he did last fortnight,
Saikia will not be able to tame the tiger
that has smelt blood. The situation calls
for sensible stratagems, not merely
showy gimmicks.
■

O. Your ad­
ministration is
seen as an ULFA
hostage. How do
you explain it?
A. We have
stopped agreeing to ulfa’s terms.
If things go on like this, we have
to crack down.
Q. But you did nothing to
get the hostages released for
over two months. Why?
A. We responded to the appeal
of some people for negotiations.
They advised me against any
harsh measures. I contacted a
cross-section of people—intellec­
tuals, teachers, journalists, lead­
ers of political parties, lawyers,
film artistes.
Q. Why do you not then
take your own decisions, as
promised?
A. My decisions are influ­
enced by views of those I consult.
It appears that I’m going soft and
my government has become a
prisoner, but it isn't so. Now my
advisers feel that the time has
come to take harsh measures.
O. Does it include army
deployment?
A. We are thinking ofthat too.
Q. Has ULFA infiltrated the
police force? Is a purge being
planned?
A. Yes. I h a ve reports th a111 lf a
boys were recruited in the police
during the agp rule. There's no
plan to purge the force as yet. but
such elements are being identified.
Q. Apparently the high
command isn’t happy.
A. That’s mere gossip. If the
Centre wasn't happy I wouldn't
have been given a free hand.

_____________|
SEPTEMBER 5(l, I99I ♦ INDIA TODAY 45

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COVER STORY

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INDIA TODAY ♦ SEPTEMBER 50, 1991

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PRASHANT PANJIAR

By MADHU JAIN and RAMESH MENON

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"T" NDIA is growing old. Fast. By the turn of the century, there
I will be 76 million Indians over the age of 60. almost the
JLentire population of Germany and twice that of most
European countries. During the past decade, the increase in
the aged population was a little over 38 per cent—the rest
went up by only 19 per cent.
Alarm bells should be ringing. The only other segment of
society multiplying at dizzying speed is the under-15s. With
such double-dependency on the comparatively sluggish mid­
dle, the question that looms frighteningly large is: whose baby
are the elderly? Especially in a
world growing increasingly
■ Longevity is
indifferent to them.
It is a question the elderly
up from 54 years
are
now asking. Never before
in 1980 to 62.
have there been so many old
people in the country. Nor so
■ India is
vulnerable. The final curtain
greying rapidly.
now falls much later. Life
In 1971, 33
expectancy today is over 62
million were
years—it was 54 just 10years
above 60. Today
a go a n d j u st a bo u 13 () yea rs i n
1947. Improved health stan­
there are 55
dards. lower infant mortality,
million. By 2000
fall in birth rates, and medical
A.D. there will
breakthroughs are ushering
be 76 million.
in a grey tide.
Consequently, life's last
two stages vanaprastha and
sanyas—when one is meant to have spurned the world—are
getting longer and death’s shadow paler. The days stretch out
likean infinite desert, monotonous and parched. “ At (St) it was
all done, now he has to continue for another 20 years.” says
Professor T.K. Oommen of the School of Social Sciences at
Delhi's Jawaharlal Nehru University.
Those extra years—when “age’s cruel knife” has already
doneits work—are no longer a bonus. At times, it is a death-inlife existence darkened by the clouds of loneliness. Tradition­
ally, age had a value in itself. The buzury were venerated
because they were old. Their word was law. Even today in
most villages, the more years you have, the greater the
deference, explains noted sociologist Professor A.M. Shah
of the Delhi School of Economics. Like Sonwati. who lives in
a village some miles from Jodhpur. To enhance her status, she
adds five years to her 75 years. Yet a silent revolution, a coup of
sorts, is taking place. The patriarch, the matriarch, the eldest
son, the aging boss, and the village elder are being elbowed
aside. The youth are moving in.
Children are even throwing their parents out. In Madras, a
70-year-old man was left to die on a pavement at Egmore by
his children. Lorry drivers finding him an eyesore decided to
hasten his end. They threw' him on a heap of broken glass.
But for Vidyavati, 90. roaming the streets of Delhi’s
SEPTEMBER 10. 1991 ♦ INDIA TODAY 47

COVER STORY
SAIBAL DAS

1

As life expectancy rises and the old lose their status, clouds of loneliness darken the extra years.
Gulmohar Park in search of shelter, it’s a living death. She
shuttled between her three daughters, until they would have
no more of her. "They say the oil on my body soils their sheets;
my cough disturbs their sleep."
Like shifting sands, change has been altering the social
landscape of the country over the past tw'o decades. Gerontol­
ogists fear that the elderly are in for a harrowing existence, as
time-honoured attitudes towards them alter. The aged are
gradually being divested of the one asset they always took for
granted: authority. "Your children looked up to you; now you
look up to them," says Shakuntala Varma, 68, whose
husband died 26 years ago. Even the literature today reflects
this displacement of the old. Writer Rajendra Yadav, who also
edits the Hindi literary magazine Hans, says that most of
the short stories he now gets depict the older people as
redundant, irrelevant.
The "contraction" ofthe joint family alone is not responsi­
ble for the marginalisation of the elderly. Complex factors like
urbanisation, the crunch on space, migration ofyoungsters to
citiesand abroad, inflation, a visible assertion of individualism
and the onset of a youth-worshipping culture are responsible
for the displacement.
Nowhere is this topsy-turvydom more manifest than in the
relationships within the family. Age was synonymous with
48

INDIA TODAY ♦ SEPTEMBER JO. 1991

wisdom, values and a host of things that made Indian society
so unique. A young nation like India prided itself on its
veneration of the old. Looking after the aged was considered
punya. In a country without social security, children are the
only insurance policy for parents. “A child is like a sapling you
plant. It will grow into a tree and in your old age you can sit
under it for shade." says Satyavati Jain, 74.
UT unfortunately, the sun bears down more harshly on
the elderly today. The old and young are often a world
apart. People take out a half-hour ritualistjcally for their
elderly parents, a snatch in the morning before going to work,
a pause between coming home and going out again to dinner,
or vanishing into their rooms.
Dacia and dadi and more often nani were institutions. They
fulfilled an important role as a bridge between their children
and their grandchildren. They were the conduits for stories
from the Ramayan and Mahabharat—before television and
Amar Chitra Katha comics usurped a role which gave them a
sense of identity. Today, the grandparents sit in a corner while
their grandchildren are glued to the small screen, video or
snowed under by school books. The ear-shattering decibels—
rock, pop or filmy—shut them out more completely.
Similarly, grandmothers have also begun to feel irrele-

I

- ■■■■

■

“Itwas a question ofprestige, /fnoti didn't look afteryour parents it would be difficult to getyour
sisters or daughters married within the community.”
—D.B. MALIK, 66, retired Hindustan Aviation Limited official

Many factors have contributed to India's greying crisis: the joint family has collapsed,
the generation gap has increased, and rapid urbanisation has created a money and
space crunch that has altered the once-respectful attitudes toward the old.
vant. Making pickles or kanji or knitting those fabulous
sweaters was a trump card ofsorts for them. Now. it is the age
ofthe ready-made. Those pickles for which you hungered now
come packaged, homely style, even labelled “Mother’s". And
clothes are off the peg. infinitely varied.
Language, or the lack ofit, often separates the generations.
The two teenaged sons of Suren Khirwadkar. 42. vicepresident of CitiBank. Bombay, can't communirate with their
grandmother—she knows only Marathi, they speak only
English and some Hindi. Often, there is a cultural stumbling
block. Muna Rana, 18. respects his 82-year-old grandfat her
but feels they have little in common. ‘ The old should look after
themselves,” he says.
Widening the chasm further are the exigencies of modern
life—the crunch of time, space and pressures. “Apartments
build walls round individuals more than families do. says
Khirwadkar. “Once the doors are closed, it’s like an
Englishman’s castle. I am busy, my sons are busy, and my
mother sits alone.”
The city enhances the
loneliness of the aged. The
unhappiest are those who
have moved from smaller
townsand villages to the met­
ros to live with their children.
There they could at least sit
on the veranda and ex­
change a few words with the
milkman, the neighbour, or
the vegetable vendor. Stuck
in a high-rise, they may look
out of the window on to a
wall. Or to yet another window with th e cu rta i ns d ra wn.
Ordown below, to life passing
by at a frenzied speed totally
alien to them.

V.M. Mangalik, 7^,
retired chief engineer,
Dehra Dun. He finds no
time to feel bored as
he runs the house,
tends
the
garden,
cooks,
plays
with
neighbourhood chil­
dren and makes him­
self socially useful.

Urbanisation and the premium on space have driven a
wedge between the old and the rest. Where there were
spacious bungalows, there are now two-room flats with
everybody treading on each other’s toes—and frayed tempers.
G. Imlay. 79. aretired railway engine driver, moved intoan oldage home in New Delhi along with his wife. “My daughter has
two rooms and five kids. I’d be cranky and grumble all lhe
time. Besides, they have an Indian-style toilet.” Privacy is al«o
a fairly new need in the cities. Children now want a room of
their own. So, in a high-pressure society, grandparents
become the odd people out, the appendages.

V A JDRSE off are those who cross cultural zones.
\ /\ / Whether it is a Mrs and Mr Swaminathan who move
V V in at the onset of their twilight years from Madurai to
Delhi to be with their children, ora Mrs and Mr Chopra who go
to their NR I children in Tampa. Florida. Interestingly, those
visits to the lands of plenty overseas are getting shorter.
Surrounded by limitless
BHAWAN SINGH
stretches of highway- often
with the idiot box their only
plug '!to animate Iife—many
elderly couples cut short their
tripsand return home. "I feel
very lonely and restless in
New Jersey. How much ice­
cream can one eat and how
much shopping can one do ■"
remarks a 72-year-old Mrs
Kannan. Besides, today more
women are going out to
work, leaving the old in the
care of servants or to
themselves.
If the old are feeling
left out in the cities, in the vil­
lages they are left behind.

1

warl

Happiness in
old age can come
only if we are not
financially or
psychologically
dependent on our
children.”

si-.!’ i

30.

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COVER STORY|
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In the autumn of their lives couples Jorge a new togetherness.
50

INDIA TODAY ♦ SEPTEMBER JO. 1991

Large-scale migration of the rural youth
to cities in search of better opportunities
has compounded the crisis for the aged.
With his son away in Delhi, Abdul
Majeed, 65. a carpenter in Uttar
Pradesh’s Tengora village, has to take
many breaks from work when aches
rack his body. If he does not make a
paltry Rs 25 a day, the family starves.
Leela, 80, says he feels like an awara
going around his village in Uttar Pra­
desh in search of some odd job. His three
sons are away in various cities and they
have their own children to look after, he
rationalises.

T"()R is it e- sy for the migrant sons
| \ I to send money regularly. Says
JL i Ramnath, 30. a cobbler in Delhi:
“We earn so little. How can we send
money home?” The elders are left be­
hind to fend for themselves. They do not
have the advantages ofmedical care and
rural development plans have not made
any appreciable dents in reaching the
rural aged.
In rural India, the semblance of
respect for the aged that existed is gradu­
ally fading. “Many of us may not really
care for our aged, but we dare not
neglect them as the community around
is always watching,” says Narsingh Pal,
60, a villager from Bulandshahr district
in Uttar Pradesh. In the cities, even
moral sanctions by society no longer
keep people from maltreating their old.
“There was a bondage to the biradari
(clan),” says D.B. Malik. 66. a retired
Hindustan Aviation Ltd official. “If you
didn’t look after your parents, it would
be difficu It to get you r sisters married. ’ ’ It
mattered what others said. Today, even
neighbours don’t know what is happen­
ing. Those old watch-dogs, the unof­
ficial ombudsmen, have gone.
Increasingly, the aged are being
discarded by the young as soon as they
have usurped their property. After
Arunachalam. 60, was found on a gar­
bage heap at Royapettah in Madras he
was taken to an institution. His family
soon turned up to retrieve him—but
only until he was made to sign off his 10acre property. Then, it was back to the
streets. Similarly, Alamelu. 84. bundled
off to an institution in Madras by her
children when her husband died, was
forced to relinquish her property.
What worries sociologists today is
the abuse of the elderly, both physical
and emotional. Hitting the headlines is
the fairly new phenomenon of crime
against the elderly. And, increasingly,
murders. “Fifty per cent of the crimes
against the elderly in Delhi involve
family members because of inheritance

-

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. J.
»

♦ —

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Lf’’*

Parsuram Bhowjani,
108, a former sales offi­
cer of a silk firm, has
four children but lives
in Bandra, Bombay,
alone and refuses to
have anything to do
with the world outside.

“I prefer
yesterday. In my
time a man was
taken at his word.
Now, everything is
legal. There's no
trust anymore."

SEPTEMBER }(), 1991 ♦ INDIA TODAY

51

severance of ties is not without pain. But guilt gets relegated to
the corners of the mind. And couples get on with the business
of life in a world moving too fast for them to carry the aged
along. That guilt, though, catches up later. Take Vijay
Aggarwal. 48, a senior executive in a Bombay multinational.
He skipped rungs on his way to the top—he was a technical
ingenue. His wife is from a far more sophisticated background
andpaints. Initially, heallowed his severely arthritic widowed
mother to stay with him. But when they moved up the social
ladderand began to entertain, the old mother didn't quite fit in
with the decor. The pangs of remorse were muffled by his
ambition and his wife's social aspirations. “I knew the
nagging won Idn '.t stop. A nd I needed peace ofmind. ’ ’ But now.
pushing the half-ccntiiry mark, the niggling doubts have
returned like Banquo s ghost and he wonders whether his
own children will do to him what he did to his mother. His
suppressed anger towards his wife now finds unexpected
outlets. He contemplates running away to an ashram.
He doesn’t though. There are many who rationalise
themselves out of this dilemma. What mitigates the guilt of
those turning their parents away—to old homes, ashrams,
other, kinder relatives or even on to the streets—are the
demands of their children and their jobs. Says a middle-aged
Bangalore executive: “Are we going to spend our savings
looking after the aged who are anyway going to die soon or are
52

INDIA I'ODAY ♦ M.I-1

we going to invest in our children who have a competitive
future ahead?" It really is a question of choice, of priorities.
"When there isn't enough milk, do you give it to your growing
child or to your parents?" asks an unabashed Saudagar Singh.
marketing consultant, in Delhi.
TN an age of conspicuous spending, each mouth to feed
I suddenly seems larger. Singh’s parents now live in two
JL small rooms at the other end of Delhi, marooned because
they can’t move out. Sometimes, when nostalgia gets the
better of him he visits them without telling his wife—and
armed with fruit and presents.
Sometimes, the elderly themselves make it easier for their
children. Aware ofthe change taking place, they seek refuge in
ashrams. Earlier they might have gone on yatras, but there
was not such a rush to build rooms in places like Hardwar,
Rishikesh, Pondicherry or Beas in Punjab. Or the need for‘Pay
and stay’ homes now being expressed or the plans for plush
residential complexes for the platinum people. "Now, when I
go at Pooja time, they besiege me with affection. That week is
lovely. And I think about it the rest of the year." says a Bengali
widow who stays in an ashram in Varanasi.
Old parents falling ill is a living nightmare for many.
Visions of Kafkaesque hospitals frighten many couples. The
honour which came with seva isn't there any more. They

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—RAJENDRA YADAV, Hindi writer
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Like an amputation, this severance of ties is not without pain. But guilt gets
relegated to the corners of the mind. And families get on with the business of life in a
world moving too fast for them to carry the aged along.

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would rather put their ailing parents in a nursing home, pay
for it, take them flowers and have their children send them getwell cards.
While sons might be falling short in their filial duties,
daughters seem to be taking on their reponsibilities. In a
fundamental role-change, more women are now looking after
their parents. Not too long ago. parents in many communities
would not even drink a glass of water in their married
daughter's house. But now perhaps because more women are
earners too. they pass more easily from nurturing their
children to nurturing their parents. “Now you even get the
kind of mother-in-law jokes you find in Italy.” says noted tv
script-writer Manohar Shyam Joshi. "Men joke about being
(jhar jamais in their own homes.”
What's lost in this quasi-banishmentofthe old from centre
stage is not quantifiable. Nor quite definable. That sense of
sanity, those solutions which can’t come out of books or
computers. Breaking with them is like removing the chains
linking us to a past, to a culture, to a civilisation. The old are
continuity itself, heirs to a collective wisdom. "With them goes
whatever dignity or grace there was in the Indian family,”
explains Punjabi writer Krishna Sobti.
The elderly may be at fault—at times they are autocratic,
unbending and demanding. But
they do keep the family together.
Somehow, they can paper over
the differences within the family.
They can keep tempers under
control. And warts of the family
hidden. And when they finally
die, their children are pushed to
the frontline.
Time may not be seen as a
"fleeing thief” as it is in the West.
Aging is not quite that fatal an
obsession in India. And death
itself not so final an event—at
least for those who believe in
reincarnation. Death is taken in

Lala Kanshirani Chawla, 104, retired govern­
ment employee, who now
lives with his son in Dehra
Dun. He writes daily in
papers on various subjects
ranging from morality to
humour.

..

a more philosophical sense and with gi cater resignation, an
acceptance of fate. But it is something the old now have to
think about for a longer period. Especially, when they lose a
spouse or friends.

Z^XLD age becomes a life-reviewing time. The burden of
I 1 memories can plummet them into depression. Often
K^Zthey are alone with their past. For Surendra Khanna.
77. a Delhi industrialist, it’s time to go. "It’s time for me.
Enough. Most of my friends have died and now their children
are going.” According to a study on aged couples in Kottayam
done by Father Jacob Cherian, as age advances, the frequency
of thinking about death increases. Shakuntala Varma lost
all her brothers and sisters. "When I am alone I keep thinking
about death. Worse, when something happens to my friends,
there’s no one to whom I can talk about it.” She describes the
past like cinema reels offaces and situations which go past her
eyes silently.
For many made to feel like burnt-out ends of h umanity. old
age may have become the ante-chamber of death. But for
others, it’s time to find new passions. Or to return to the
forgotten ones. J.R.D. Tata re-energised life in his eighth
decade by making family planning a personal crusade. Others
are “adding life to years” by
BHAWAN SINGH
chasing causes- -whether it's
H.D. Shourie who in his late 70s
is battling on for civic issues or
Lakshmi Menon, 93. an external
affairs minister of state with
Nehru and Shastri, who nips
round in her capacity as presi­
dent of the All-India Committee
for Eradication of Illiteracy
among Women.
Others find second careers.
Kranti. 64. a retired government
engineer, has opened a show­
room tor electrical goods in his
house in Delhi to fill those empty

“Values and
priorities have
changed. Gone are
the days when being
an aged person was
an advantage.”

SEl’ I l-.MBEK 10. 1991 ♦ I X 1)1 A TODAY

53

COVER STORY
PRASHANT PANJIAR

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Not only their wealth, the old increasingly want to take good care oj their health too.
hours. A growing number contribute their skills—as accoun­
tants or taxmen—to religious organisations like the Rama­
krishna Mission. Many teach children Urdu or impart reli­
gious training at various madrasas.
And then there are the old who escape feeling old by
looking after the old. M.M. Sabharwal, 70, who has been
chairman of dozens of company boards is now chairman of
Helpage and raises money for the elderly. None of these
individuals consider themselves old—old is other people.
This last act of life is also the time for renewal. For eminent
painter K.G. Subramanyam, in his 70s. this is the age to see life
more clearly—without that meddlesome “passion coming in
the way, like maya". The canvasses of Bhabesh Sanyal. 95.
have the clarity and joie de vivre found in the drawings of
children.
The grey brigade is now striking back. India does not have
any “Grey Panthers’’—the group of elderly Americans who
fought for their rights. But some elderly people have begun to
organise themselves over the past decade. In addition to
Helpage India and Age-Care India, there are nearly a dozen
groups like the Senior Citizens Federation. Indian Federation
on Aging and National Federation for Senior Citizens, which
are actively lobbying for various demands. The demands
include 50-per cent concession in rail fare, separate geriatric
wards, a network of ‘Pay and stay’ hostels for the elderly,
54

INDIA TODAY ♦ SEPTEMBER ?(), 1991

patterned on the working women's hostels. Major R.S.Pannu,
director-general of Helpage India, suggests that planners
should create a “grey skills bank’’ where the aged can be
converted from liabilities to assets by profiting from their
vast experience.
| 1|VEN more significant, there is a new. more upbeat mood
r-< evident. M.S. Rana who at 81 thinks he’s “not old but
-L4 only disabled" believes that people like him must spend
on themselves. “We should dress well, look after ourselves and
enjoy life.’’ Every first Sunday of the month a group of about a
dozen aged people in Delhi gather to “meet and eat" in a coffee
house. ‘‘We don’t talk about our children or grandchildren.
We talk about the neighbours or what theirdaughter is up to,"
he says with a mischievous twinkle.
Some go on holidays, as opposed to just pilgrimages.
Delhi's Mrs Varma and two other friends even older than her,
went to Orissa and spent the whole day on the beach. “I'm not
ready to sit in a corner with a mala and bhajans.”
Others are tackling their truant offspring head-on. An
elderly widower who had been shunted to the garage of his
own house by his daughter-in-law sold the house while his
family was on vacation. Yet another, on the advice of his
friends, informed his son’s office that he was not giving him
any house rent—his son was claiming hra from his employ-

"‘Life seemed eternal while they were there. As long as the parents are alive you don ft really think
of death, then you are next”
—RAJAN PRASAD, university professor
1

For many, old age may have become a wait for death, a long winter of
neglect. But for others it’s a second summer of renewal, the age to see life more
clearly, the time to slough off cares and responsibilities. And death in itself is
not so final an event, at least for those who believe in reincarnation.
ers. Promptly, the son not only started paying his father but
stopped abusing him.
As India greys, new areas open up for innovative entrepre­
neurs. Beauty care, tonics, restoratives, so-called vitalisers
like ginseng herb, travel and housing schemes, get a new
clientele. Anjana Handa who runs a soft laser treatment clinic
in New Delhi claims that she is besieged by callers—all above
45 wanting their wrinkles and sagging skin to vanish.
Increasingly, the aged want to look good and exercise more
than they ever did before.

f | I IE aged have painfully realised that they must keep
|! their wealth with them. They are no more willing away
_JL property to children or giving them ail their property on
a platter. The proverbial lady with the trunkful of jewels and
possessions is now beginning to put her money in the bank.
The old now hove fixed deposits stashed away and make sure
they have enough money to make them financially indepen­
dent. Says Vidyaratna, 71. a retired education officer, who
lives in a Hard war ashram with his wife: “If we have money,
everyone respects us. Even our children." In his ashram, there
are nearly 300 couples living a totally independent life, in
separate houses and running their own kitchens. Almost all of
them are financially independent. Their children drop in to see
them but few have any illusions—they know they do so

because of their bank deposits.
There's also a silver lining to the grey clouds. Sometimes,
there is love in the timeofold age. Couples may ha vesquabbled
all their lives but in the autumn of their lives, the bonding
between them strengthens. Old age often leads to a reordering
of relationships among couples who battle loneliness. Some
understand what love means only in their twilight years, says
Bangalore-based psychotherapist Carlos Welch.
There are stirrings of a sort of an old people’s liberation
movement. But the vast majority is still at the mercy of their
children or fate. With India greying so rapidly, the Govern­
ment is still Rip Van Winkle-like about the phenomenon. No
five-year plan has yet recognised the needs of the aged. At the
World Assembly of Aging held in Vienna in 1982 it declared
that “aging in India should not be viewed with anxiety".
Eminent sociologist M.N. Srinivas says the only way to
avert a crisis is to create a consciousness ofIndia getting greyer
so that society is geared to meet the challenge in terms of
infrastructure. Clearly, India needs to plan ahead for the aged.
Going the way of the West with homes for the aged is
perhaps not the best answer. But the need to weave the aged
back into the tapestry of life and not let them be isolated at its
borders has never been so great.

(Some of the names have been changed to protect the privacy of the
pramod pushkarna
persons quoted.)

Devaki
Aggarwal,
68, a retired school
principal, lives on three
tin trunks on a New
Delhi pavement, un­
wanted and uncared
for,
after
relatives
turned her out.

“My family comes
to see me live on
the roadside. But
they will not give
me their current
address. They do
not want me.’’

SEPTEMBER JO. 1991 ♦ INDIA TODAY

55

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X\|mphon\|
THE

FROM
HOUSE
OF

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AGEING
a symposium on

the greying of

our society

symposium participants
12

THE PROBLEM

14

NATIONAL POLICY' ON OLDER PERSONS
C.P. Sujaya. Principal Secretary. Government of
Himachal Pradesh, Shimla

21

AGEISM
Vinay Kumar Srivastava, Depanment of Anthropology,
University of Delhi

26

SOCIAL AGEING IN INDIA AND AMERICA
John van VVUligen. Department of Anthropology.
University of Kentucky, USA

30

AGEING PAINS
Smita Kishore. Lecturer, Depanment of Sociology,
Isabella Thobum College, Lucknow

35

DEMOGRAPHIC TRANSITION
Ashish Bose. Emeritus Professor of Demography,
Institute of Economic Growth, Delhi; Member, Independent
Commission on Health in India

40

-HEALTH ISSUES
P.C. Joshi, Associate Professor of Medical Anthropology
and S.N. Sengupta. Associate Professor of Psychiatry,
Institute of Human Behaviour and Allied Sciences, Delhi

44

SOCIETAL RESPONSES
Mala Kapur Shankardass, Sociologist; Reader,
Maitreyi College. Delhi University; Chairperson,
Development Welfare and Research Foundation, Delhi

48

INTERVIEW
With M.M. Sabharwal, President Emeritus, HelpAge India,
by Mala K. Shankardass. Delhi

51

THE LAST SCENE
Mohammad Talib. Professor, Depanment of Sociology,
Jamia Millia Islamia. Delhi

55

OMISSION-COMMISSION
Shod story by Vijay Dan Detha and Komal Kothari.
Transcreated by Mohmaya, Jaipur.

57

BOOKS
Reviewed by Vinay Kumar Srivastava. Annie Koshi,
Bhavna Puri and Meera Ahmad

65

FURTHER READING
A short and select bibliography

68

COMMENT
Received from Nandini Sundar. Associate Professor of
Sociology. Institute of Economic Growth. Delhi

74

BACKPAGE

a short statement
on the issues involved

COVER
Designed by Akila Seshasayee

4-

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The problem

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12

‘An old man loved is winter with flowers’ (old German
proverb).* To a society and culture.that has long prided
itself in its veneration of the elderly (witness the popu­
larity of the Shravan Kumar story), the existential
reality of the aged may come as a surprise. Our older
citizens, on a daily basis, are reminded both of their
expendability as also of the deepening coarseness
society displays towards them. Be it the way they are
treated within the family, the woeful inadequacy of
healthcare provisions directed towards the old, and
above all the increasing incidence of the violence
they face - it is evident that modem Indian society is
ill-prepared to meet the challenges posed by the grey­
ing of its population.
A part of this problem can be traced to material
scarcities. Most societies, the poorer ones even more
so, find it difficult to set aside scarce resources to take
care of the elderly. Given the widespread application
of the framework of triage, the elderly and infirm are
invariably passed over in favour of those classified as
productive and useful. Butequally, the problem lies in
the fetishization of youth. Modern industrial and post
industrial cultures foreground the vitality and energy
of the young as against the wisdom and experience of
the old. And even though we have yet to approximate
the western obsession with remaining young, we are
clearly getting there.
It is likely that in earlier times ageing as a social
problem did not preoccupy societies. Life expectancy
was in any case low. Since only a few survived for long
years, it was easier to either venerate thefti as reposi­
tories of wisdom and tradition or create social mecha­
nisms which encouraged the aged to step away from
the management of everyday concerns. The notions of
* Folio. October 1998.

Ageing

vanaprastha and sanyasa probably evolved as a
response to the need of displacing the old.
With an increasing proportion of our population
living for ever longer years, we are now confronted
with the problem of not knowing what to do with our
elderly citizens. Simultaneously, our senior citizens
too are challenged by how to creatively and usefully
occupy themselves, and that in asociety which displays
little patience for the old. The joint family, long held
out as our answer to this problem, is neither as wide­
spread as popularly believed, nor does it seem capable
of accommodating the pressures created by the demands
of a modem urban and industrialized lifesty le.
If honourable living within a joint, multigenerational family has become difficult, a dignified
separate existence too is not easy. Be it ensuring eco­
nomic and physical security or accessing basic ser­
vices, including healthcare, everyday living often
creates trauma for our elderly. Far worse is the expres­
sion of societal neglect and unconcern. Increasingly
pushed into mining their own resources, both economic
and emotional, the aged are increasingly thrown into
their own age cohorts, a process that can only
strengthen feelings of alienation.
Such at least is the picture presented in our mass
media or through the popular soaps and films. Even the
more sensitive Bollywood productions, Saransh or 36
Chowringhee Lane, paint the elderly protagonists as
somewhat feeble and helpless, unable to bring joy and
meaning into their lives without an active association
with the young. Just take an early morning walk and
listen to the conversation of the old. It is either full of
pride about successful children or, more frequently,
about how they are treated within the household. The
speech is marked by anguish and insecurity. Little won­
der that so many older people are unwilling to settle

their property matters, fearful that in the absence of
economic resources they may be forced to move out.
Those who live on their own, a phenomenon now
fairly widespread, are obsessed with issues of physi­
cal security, not surprising given the incidence of
crimes targeting the old. The difficulties they face in
accessing basic services-from medical to recreational
- are legion. Over-riding all these is a feeling of lone­
liness and worthlessness.
Unfortunately, detailed research on the aged is
hard to come by. For a start, even basic demographic
data is only now being subject to detailed analysis. In
the absence of indepth anthropological studies on the
joint family system, both regionally and for different
socio-cultural groups, we continue to believe in its
resilience. We need to map out how our aged live within joint families, alone, in ashrams or old age
homes, where? Why is it that institutional care for the
elderly - be it day care centres or residential homes is more widespread in the West and South rather
than the North. And above all, we need to improve
ourunderstanding of the non-urban middle class world.
Far too often, both our understanding and conse­
quent policy recommendations are overly conditioned
by our middle class worldview.
In particular, we need to direct our attention
towards the special problems faced by old women,
more so widows. Except when controversies of the
kind generated by the filming of Water arise, as a soci­
ety we remain supremely unconcerned about their
fate. In urban, middle class households they are reduced
to the level of unpaid help; in rural and tribal society
they are left to fend for themselves.
The government has recently formulated a
national policy for older persons, listing out a range
of social welfare measures targetted towards the

elderly. A few states, notably Himachal Pradesh, have
even experimented with legislating for the elderly,
mandating them as a legal charge on their children.
While the merits or otherwise of the proposed policy
will continue to be debated, it remains a matter of
concern that we have increasingly to rely on the state
to provision for our elderly and that inter-generational
relationships have to be recast in the language of legal
rights and entitlements. As H.Y. Sharada Prasad,
in a recent column in Asian Age presciently pointed
out, ‘ It is not the government that has elderly parents,
but we. It is up to us to take the initiative in protecting
them.’
It is heartening that civil society has taken some
steps in this direction, be it through setting up day care
centres, old age residential homes, organising recrea­
tional activities for the elderly, arranging care of the
indigent or terminally ill, and so on.The medical estab­
lishment too has got sensitized to the special problems
faced by the elderly, both physiological and psycho­
logical. More important, the elder citizens have begun
to organise themselves in forums for mutual support,
as pressure groups for policy changes and so on. Out­
side the family, many older people have become
active participants in NGOs, in helping improve civic
life, in brief, carving out an active and useful role for
themselves. The last in particular has been crucial in
helping break the image of the elderly as dependant.
As long as we continue to perceive olderpersons
as a problem, it will be difficult to move out of a utili­
tarian and instrumental focus. A civilized society
must create conditions such that the aged can live lives
of self-worth and dignity, more a source of joy than a
burden. This issue of Seminar examines some of these
concerns. There is no getting away from the fact that
the elderly are today what we will be tomorrow.
SEMINAR 488 - April 2000

' 'c”f

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'

13

National policy on older persons
C.P. SUJAYA

SINCE the time when development
planning was initiated in independent
India, the state has recognised older
persons as a priority target group for
social welfare interventions. The
Directive Principles of State Policy
in our Constitution enjoin the state to
provide public assistance to older
persons within the limits of its eco­
nomic capacity. The early social wel­
fare interventions for this group
included old age pension and shelter.
These were introduced by state gov­
ernments in the’50s and the ’60s and
now most states have some form of old
age pension scheme. Additional wel­
fare schemes were launched in the
succeeding decades.
The social welfare approach
was conditioned by humane princi­
ples. Older persons were perceived
as the natural recipients of welfare
handouts, doles and institutionalised

14

i

Ageing

I
I

services. The state did not view them
as a resource or as active participants
in planning their own development
and welfare. On the other hand, the
state governments found that there
were severe financial constraints in
expanding these social welfa
schemes to cover larger numbers u*
olderpersons.
The coverage of the population
as well as the quantum of individual
pension granted under the scheme
remained minuscule. It became an
ameliorative measure, aimed more at
preventing destitution and penury
rather than covering risks attendant
with old age. This absence of an effec­
tive and comprehensive framework
of social security assistance for the
overwhelming majority of the older
citizens continues to date.
The National Policy on Older
Persons was announced by the gov-

ernment in 1999, declared as the International Year of Older Persons by the
UN. The year 2000 has been declared
as the National Year of Older Persons
by theGovemmentoflndia.Thedecision to frame a policy forolder persons
was first mooted in the ’80s, follow­
ing the World Assembly on Ageing
held at Vienna in 1982. In 1987-88
an Inter Ministerial Committee was
constituted by the GOI for this pur­
pose. The process of formulating the
policy gathered momentum in the
two years preceding 1999. According
to ministry officials, the process envisaged active involvement of voluntary
organisations, research bodies, schools
of social work, and so on. A number
of regional consultations were 1held
along with a national level consultation to discuss the draft policy document prepared by the ministry for
getting feedback from a broad range
of positions and approaches.

he national policy reflects a few
basic and interlinkingconcems.These
include the impact of demographic
changes overtaking the country’s
population in the wake of an increase
in health coverage and the adoption
ot the small family norm resulting in
an increase in
in the responsibility of
the working .population
for
.
' elderly
’/
care;; the magnitude of the task of
reaching even minimal social ass­
istance to the large numbers of the
elderly; the effect of the changes in
the economy due to urbanisation and
industrialisation; and the introduc­
tion of new technology and new life
styles and values on the structure and
functioning of families and theircapacity to care for the elderly, j

I
t

i

The policy highlights the plight
of the vulnerable within the older
person’s category such as widows,
women in general, the poor, rural resi­
dents, the disabled and chronically
(including mentally) ill and others.

Since the below poverty line
population of older persons will continue to rise (due to falling death rates
and no discernible decrease in poverty
iratios), the commitment of ensuring
full coverage will be a never-ending
task. Even at present the population
above 60 years in the country is estimated at a huge 67.2 million (1995),
only a fraction of which is covered
by the old age pension and other
I
schemes meant to address destituIndeed, it is difficult to take these tion (such as pension for agricultural
grand promises seriously, or envisage labourers, unemployment relief, and
from where the funds for some of the so on, some of which may be accessed
new state interventions promised in by older persons). While there are no
the policy, even under such important available figures showing the number
heads as health, shelter and welfare, of older persons who are below the
will be found given the precarious poverty line, the incidence of poverty
financial position of the governmentt can be assumed to be higher in the
in the era of reforms, especially in the older age groups th.lan in the general
underfunded social sector.
population,
For example, the policy com­
mits to increase the coverage under the The policy statement itself has relied
old pension scheme from the January
1997 level of 2.76 million to include on the figure of 33% of the general
all older persons under the poverty population and concluded that one
fline. But
" it does not specify the number third of the population in the60+age
of older persons below the poverty group is below the poverty line. This
line who are to be covered if this com- may be an understatement. Still,
mitment is to be fulfilled. Nor does it accepting this figure, the number of
speak of any probable deadline or poor older persons comes to about 23
phased deadlines by which the gov- million. Surveys from different sourernment plans to complete this cover- ces show high numbers of chronically
age - or the magnitude of funds ill and disabled persons among the eldrequired to complete this gigantic erly. They also show that the elderly
task. The present pension rates paid continue to work long after 60 years
to olderpersons throughout the coun- and that their average earnings> are
try (Rs 30 to 250 per month) affords much lower than in other age groups,
no income or livelihood security. The burden of providing universal
It is only a token payment to ward coverage ofold age pension to the eldoff extreme destitution. Though the erly poor, even within a phased period,
policy speaks of revising the rate att therefore, seems beyond the capacity
intervals so that ‘inflation does not of the government given its financial
deflate its real purchasing power’, position and a realistic perspective.
no details have been given to show
The same is true of other sectoral <
whether the base rate existing at pre­ interventions mentioned in the docu­
sent will be protected through index­ ment, such as strengthening the pri­
ing or whether a total review will be mary health care system and public 15
done on the basis of the need for eco­ health services, providing geriatric
nomic sustenance.
care facilities at secondary and tertiThe national policy is open
ended. It promises an array of state
interventions - support for financial
security, health care, shelter and welfare, special focus on older women,
protection against abuse and exploitation and special attention to rural
areas. It also recognises that the state
by itself cannot achieve these objectives, except partially.
:;

SEMINAR 488 - April 2000

I

ary levels, starting new specialisedI reorient, modify existing programmes
courses in geriatric medicine, starting to reach the olderpersons? How much
mobile health services for the ailing clout does the Ministry of Social Jusold persons, meeting the education, tice and Empowerment have with
training and information needs of the other important ministries to ensure
older persons, and so on.
that the issues relating to older persons
The policy document, in so far are given more importance in all their
as these commitments relating to state programmes?
interventions are concerned, can at
best be seen as a statement of intent. The policy refers to the legal rights
The addition of a financial memoran­
dum or the formulation of a plan of of parents without any means to be
action to implement the policy would supported by their children having
have significantly improved its cred­ sufficient means. These rights are
ibility and helped nail the policy down enshrined in the Cr. PC as well as in
to the immediate tasks and sort out the HinduAdoption and Maintenance
the medium and long term action per-'' Act 1956. The policy refers approvspectives. Though policies are not ingly to the action taken by two state
expected to spell out everything in governments in introducing relevant
minute detail, it is incumbent on the legislation at the state level and speaks
government to plan the implementa- of encouraging other states to pass
tion strategies, sequence the actions similar legislation so tthat old parents

and, above all, garner its resources unable to maintain themselves do not
and match the plans and commitments face ‘abandonment and acute neglect.’
with the needed funds.
The provisions of Cr. PC and HAMA
are seldom used by parents to go to
PI
court against the children. Most litiISutthere is no mention in the docu- gants under Section 125 of Cr. PC are
ment about the financial implications spouses, that is, wives. The provision
of carrying out the commitments for maintenance of parents by chilmade in the policy or from where these dren, wives by husbands, etc. under
resources are going to be arranged in these statutes, however, is not to pro­
all the sectors. All that the policy con­ vide minimum income or old age
tains is a statement that an action plan security but to prevent destitution and
will be prepared by the government. vagrancy. It cannot, therefore, substithat the^olicy itself will be widely tute for state action in providing risk
disseminated and ‘its features remain cover to older persons.
Though the Himachal Pradesh
in constant focus’. But in the one year
that has elapsed since the policy was Maintenance of Parents and Depenannounced, no plan of action has dants Bill was passed by the state
been formulated. The ministry, per­ assembly in 1996, it still awaits Presihaps, is engaged in such an exercise dential assent.The bill empowers any
person unable to maintain himself,
at present.
Questions of financial capacity, who is resident in the state, to apply
capability and viability arise, there- to the tribunal for an order directing
, fore, from a plain reading of the many the children, grandchildren, husband,
commitments of state action made in father or mother as the case may be, to
the policy by the government. How pay him a monthly allowance or any
16 much can the government afford to other periodic payment of a lump sum
spend on new schemes for older per­ for his maintenance. The bill is aimed
sons or to upgrade, improve, train. at providing relief not only to indigent
Ageing

parents (above 60 years) but to wives,
children and dependants who> are in
a similar situation. The inability to
maintain oneself is defined as not
being able to meet the expenditure
on basic amenities to meet physical
needs including, but not limited to,
shelter, food and clothing from his
total or expected income and other
financial resources.
Two mechanisms have been
created in the bill, namely those of
‘maintenance officer’ and ‘approved
person or organisation’. The former
is invested with the duty to help appl icants in any legal proceedings under
the act as well as to appear before t.
court on their behalf. He can consult
the parties concerned and bring about
reconciliation; he can authorise underunder­
age applicants to ask for relief if he is
satisfied that infirmity of mind or body
makes it difficult for the persons to
maintain themselves.

The ‘approved persons or organisa­
tions’ are those bodies engaged in
social welfare or family welfare or
others5 as approved by the state gov­
ernment ‘whose association with a tri­
bunal would enable it to exercise its
jurisdiction more effectively in accordance with the purpose of this Act ’
These organisations are authorisec
defray the expenses on maintenance
of the persons who have been granted
relief by the tribunal and claim reimbursement from the state.
The bill provides that lawyers
shall not appear before the tribunal or
represent any party. The maximum
period of time to decide the application by the tribunal is six month from
the date of application.The bill authorises the attachment of salary payable
to any person against whom a maintenance order has been passed and who
is employed by the state or centra
government or by a local authority or
from a corporation engaged in any

trade or industry which is established
by the state or central government, or
by a government company.

lhere is a real reluctance on the
part of parents to go to court against
children. Though the Himachal Pradesh bill has some attractive features,
including involvement of social orga­
nisations in the legal process, simpli­
fication of legal procedures, flexibility
regarding age limits, ease of attach­
ment of salaries, conciliation process,
among others, it remains to be seen
how often the statute will be made
use of by olderpersons as compared

i

1

!

to the other groups eligible to ask for
relief, such as children and spouses.
The concerns of older persons
arecross-cutting.relatingtomanydifferent departments and ministries
within the government. So far the
needs and requirements of older persons were subsumed under the rubric
of‘welfare’ or ‘social welfare’. Only
the very poor or the destitute were
directly targeted. Now the policy statement makes a break with the past
by spelling out ‘the principles... the
directions, the needs that will be
addressed and the relative roles of
government and non-government
institutions’ to carve out ‘respective
areas of operation and action in the
direction of a humane age-integrated
society.’Thepolicyfurtherstatesthat
the thrust is‘on active and productive
involvement of older persons and not
just their care.’
This holistic approach toward
olderpersons is sustained in the policy
by identifying priorities such as social
assistance and security, health, shelter, education, freedom from abuse
and exploitation, research, training
and manpower, besides several others.
The challenge of implementing such
a multi-level and multi-dimensional
mandate is enormous. It calls for coordination, leadership, effective stra-

ment of flats on the ground floor
(para 49 of the policy);
* education: ‘discrimination... against
older persons for availing opportunities foreducation, training and orien­
tation will be removed... assistance
for open universities will be sought
to develop packages using distance
learning techniques... educational
|
curriculum at all stages of formal eduI n May 1999, the ministry notified a cation as also non formal education

tegizing, networking, lobbying and
advocacy. Above all, it calls foreffective monitoring, feedback and continuous system improvement. The
institutional mechanisms that are in
place or are being set up to oversee the
policy implementation are therefore
t
of crucial significance,

39-member National Council for
Older Persons under the Minister for
SJE to advise, provide feedback, act
as a lobby and advocacy forum, and
deal with complaints from individuals. This body has representation
from a few central ministries such as
pensions, defence, railways, commu­
nications as well as from three state
governments by rotation. A repre­
sentative each from the National
Commission for Women and the
National Human RightsCommission
finds place on the NCOP. But ministries dealing with a number of important aspects of the subject of ageing
and older persons, such as the following, have not been represented on the
Council.
* health care and nutrition: ‘health
care needs of older persons will be
given high priority’ (para 34 of the
policy), ‘the primary health care systern will... be strengthened and oriented to meet the health care needs of
olderpersons’(para35ofthepolicy);
* shelter: ‘housing schemes for urban
and rural lower income segments will
earmark 10% of the houses/house
sites for allotment to older persons...
older persons will be given easy access
to loans for purchase of housing and
for major repairs with easy repayment
schedules’ (para 48 of the policy), ‘a
multi-purpose centre for older per­
sons is a necessity for social interaction and... it will... be necessary to
earmark
earmark sites
sites for
for such
such centres
centres in
in all
all
housing colonies... preferences will
be given to older persons in the allot-

programmes will incorporate material to strengthen intergenerational
bonds and mutually supporting relationships’ (para56);
*law: ‘the introduction of special pro­
visions in IPC to protect older persons
from domestic violence will be con­
sidered and machinery provided to
attend to all such cases promptly...
Tenancy legislation will be reviewed
so that the rights of occupancy of older
persons are restored speedily’(para 65
ofthepolicy).
* media', ‘the policy aims to involve
mass media ...on ageing issues... to
provide opportunities to media personnel to have access to information
apart from their own independent
sources. .. their participation in orien­
tation programmes on ageing will be
facilitated’ (para 89 of the policy);
* rural areas, where the bulk of the
older persons live, (in absolute terms
as well as in terms of proportion of the
population) and who are poorer, less
literate and expect to live less than
theirurban counterparts; and
* labour, which deals with the prob­
lems of the unorganised workers in the
country as well as with pension and
social security.
The bulk of NCOP’s members are

experienced and well-known indi­
viduals from a wide range of backgrounds, including NGOs, citizen’s
groups, retired person’s associations,
law, social welfare and security,
research, and medicine. The NCOP
SEMINAR 488 - April 2000

7-. — ............................................... -.........

17

is said to have not met so far. Asmailer
working group consisting of seven
members of the NCOP has been set up
to transact business on its behalf,
which meets more frequently and con­
sists of representatives of voluntary
organisations, experts and other lumi­
naries. It is chaired by the secretary of
the ministry.

18

and deliberations of the council, and policy categorises two-thirds of the
to what extent the council itself, given population above 60 years as eco­
its unwieldy size, can foster coordi­ nomically ‘fragile’ out of which one
nation among the sectors of health, half is below the poverty line and the
housing and shelter, law, nutrition, other half is above it, but belongs to
education, rural development, and the lower income group.
labour, in advocating the cause of
older persons and confronting prevail­ \A/hile the expressed need to incre­
ing negative attitudes towards them.
Ageism and discrimination ase the coverage of old age pensions
The secretariat of the National Coun­ against the more vulnerable groups to all those below the poverty line
among the older persons has to be spe­ receives top priority in the document,
cil, Aadhar, is located in Agewell, a cially countered. The policy speaks the policy calls for a new pension
voluntary organisation working with of action plans to be prepared by each scheme to be established for selfelderly citizens. Besides providing ministry of the government to imple­ employed and salaried persons with
assistance to the council, it is mandated ment those components of the policy provision foremployers to contribute.
to look into individual grievances of which concern it. It speaks of ensur­ This will be overseen by a strong
olderpersons, set up a voluntary net­ ing flow of benefits to the older per­ regulatory authority which will make
work at district level throughout the sons from general programmes, as investment norms and safeguard
country, compile dataand information well as from special programmes pension funds. It is not clear for
relating to ageing and older persons, and schemes exclusively aimed at which economic category or socio­
and carry on advocacy and awareness the olderpersons. Itenjoinseach min­ economic class or classes this new
programmes.
istry to decide on targets, time sched­ pension scheme is intended.
Launched in November 1999, ules, responsibilities, action points
In pursuance of the policy com­
Aadhar had, up to the middle of Feb­ and report on progress in the annual mitment, the ministry appointed an
expert committee ‘to comprehen­
ruary' 2000, initiated a process of set­ reports.
ting up voluntary action groups at
sively examine pol icy questions con­
the district level throughout the coun­ i^kkll this calls for a high order of nected with old age income security.’
One report dealing with improvingthe
try in consultation with the deputy
commissioners/collectorsand volags. horizontal coordination between existing pension provisions was sub­
It has been able to identify nearly different government agencies. The mitted to the government in 1999.The
2300 individuals in over 120 districts appropriate instrument to facilitate second report, dealing with ‘a new
to work on a voluntary basis for the this is an inter-ministerial committee pension provision forexcluded work­
which, though envisaged as a part of ers who are capable of saving even
cause ofolder persons.
Aadhar is also formulating a the institutional set up. has yet to be set modest amounts and converting this
strategy for handling individual letters up. Such acommittee should be given saving into an old age income security
of grievance orcomplaints from older the task of monitoring policy imple­ provision’ was submitted to the gov­
persons. These are received by the min­ mentation in as much as it relates to the ernment in mid-January this year.
Looking at the problem of social
istry7 from a variety of sources and nor­ ministries and the state governments.
security
from the vantage point of the
It
should
also
look
for
appropriate
mally dealt with cursorily in the usual
neediest,
there is no doubt that the
bureaucratic style. It has received strategies for networking within and
most vulnerable categories of older
over 700 such letters, most of them outside the government agencies.
We now look at some crucial persons are those who have worked
from the Ministry of SJE, and is cur­
rently reviewing them to find solu­ issues related to the policy on older or may still be working as landless
agricultural workers, small and mar­
tions and identify interactions with persons:
ginal farmers, artisans in the infor­
1.
Social-assistance
for
the
olderper
­
the concerned authorities.
While the idea of locating the sons. The policy adopts a segmented mal sector, unskilled labourers on
secretariat of the national council in approach to the provision of income daily, casual or contract basis, migrant
a voluntary organisation is innovati ve, security forolderpersons (‘policy ins­ labour, informal self-employed or
it remains to be seen how effective truments to cover different income wage workers in the urban sector, and
Aadhar will be in shaping the agenda segments will be developed’). The domestic workers. These categories

Ageing

of persons have little or no job secu- and services and has increasingly
In discussing financial security
rity nor any form of social security.
been a serious drain on government ofolderpersons, the policy statement
While a few state governments finances.’.The other is that ‘the sheer shows a greater involvement with
have provided some succour to these number of the elderly is too large issues relating to pension and social
groups through special pension and the resources with the state are security of workers in the urban and
schemes and unemployment relief, too small to make anti-poverty pro- formal sectors of employment. The
their coverage is extremely thin.The grammes the central plank in thinking need to improve the procedures of
condition
these r-itivAnc
citizens is
rnnHitinn of
nftUc
ic most pre­ about the elderly..that government settlement of pension cases, improvecarious as their engagement with the dole is not sustainable on a sigmfi- ment of investments and accumulalabour force is intermittent and they cant . scale.’ Another .observation tions in the provident funds, more
are subject to long spells of no work. made in the report is that ‘India faces efficient disposal of gratuity and other
They also have to continue working severe problems of poverty among retirement benefits, have received
long past the age of 60 or 65 years, if the elderly.’
greaterattention in the document.
health permits, forsheersurvival.The
The policy refers to the need
concept of the age of retirement does
for a strong regulatory authority to
not exist for them, nor does saving in I ” overty among the older persons oversee pension schemes and penyouth forold age have much meaning, is a direct consequence ofthe lack of sion fund management. There’ are
Levels of indebtedness among income and livelihood security during references to taxation policies and the
these groups speaks volumes about the productive years of the vast majo- need to reflect sensitively tothefinantheir lack of capacity to save.. The rity of the rural and urban workers cial problems of older persons in the
loans are taken fora mix of consump- who are outside the formal or organ- matter of standard deduction, annual
tion and other ‘productive’ needs. This ised employment ‘sheds’, which itself rebate for medical treatment, etc., all
strata is increasing since the opening is the result of the failure of develop- aimedatthe income tax paying minoup of the economy to market forces, ment planning. Second, anti-poverty rity in the country.
the loosening of controls and the in­ programmes are primarily aimed at
creasing stress on industry to become providing a wage or self employment,
globally competitive has increased and not doles. Third, attempts at comimilarly, references to post retire­
casualisation of labour.
bining thrift and credit activities
ment employment, income generat­
with anti-poverty programmes have ing activities after retirement, career
been quite successful in recent years, guidance and counselling and training
It is doubtful if the new pension To focus on poverty among older are obviously targeted at the better­
scheme recommended by the Pro­ persons without its political economy off sections in the country. Summing
ject OASIS expert committee would will not leadI us to any sustainable up, the policy statement on social
address the particular situation and solution forcontaining the problem of assistance and security for older percontext of the older persons who be- old age destitution.
sons has not given any meaningful
long to this most vulnerable group of
The pension scheme is meant for recommendation for improving&the
citizens in the country, even assuming persons who at a minimum save Rs 5 later years of the largest group of in­
that the below poverty households are per day. Research by Project OASIS come and asset poor rural and urban
not included in the scheme in view of has found that only if this saving is sus- poor.
the government’s policy commitment tained throughout the working life (of 2. Issues relating to older women —
to cover them under the old age pen- 35 years presumably), will it result in legal rights. While there are a few
sion scheme.
escaping the poverty line in old age, ireferences
'
’in the
' \policy statement to
not possible
to present
an
-ItVis1--------— v... provided
the pension assets are inve- the gender based status of marginain-depth critique of this proposal in sted wisely. The project assumes an lisation and vulnerability of
- older
••
the paper. It ts learnt that the OASIS extremely large number of people women, there is no concrete recom­
report is being examined by the minis- who can save between Rs 3 to Rs 5 mendation which ttUUlV(
,ovo. their
addresses
try. However, some of its premises are per day and thus prepare themselves particular circumstances on account
self-explanatory. One is that ‘higher for old age income security. However, of gender and age. Though reference
government spending on old age secu- the report presents no data on house- is made in the policy statement to
19
. • .
* • ,,a
rity has often been at the cost ofexpen- hold expenditures or levels of indebt- higherincidence
of widowhood, there
diture on other important public goods edness to sustain this assumption.
is no mention of a need to review the

Q

■

SEMINAR 488 - April 2000

■

...

larger society. Added to this, in the changes such as an increase in widow
later years, is ‘ageism’ defined as a pension or adding to the support serv­
process of systematic stereotyping ices available, are possible. The wom­
en’s movement in India has not paid
cause women lack both social and and discrimination against old peo­
sufficient attention to the predicament
economic support. Ageism and patri- ple because they are old... and allows
hy combine to make older women younger generation to see them as of older
in the c^^rya
arcl
vulnerable among older different from themselves...
at
times
many
movements
and campain
..
the most
ageism becomes an expedient method for legal reform by women s groups
persons. Abuse of older persons has
hv whichsocietvnromotes
viewpoints should identify the peculiar circumbeen mentioned in the policy but no byy which society
..promotes viewpoints
.
.
special reference to violence against about the aged in order to relieve itself stances in which older women have
been placed on account of their lack
older women finds place. The intro­ from responsibility toward them.
of legal entitlements.
duction of special provisions in the
Indian Penal Code to protect older Though the codification of Hindu
I References
persons from domestic violence is,
the 1950s has been hailed as The National Policy on Older Persons Govhowever, a welcome
------------feature, as is the laws in l..~----------women of emment of India. Ministry of Social Justice
commitment to create a machinery to s a great breakthrough tor• women
women of
Empowerment. Shastri Bhawan, Nev
'the majority community in India, Delhij999.
' promptly attend to all such cases.
ground experience tells us that wornMemorandum of Constitution of the
°
_ _
.J
— . .
zk rr’/^nj
en’s access to residence, property and National Council for Older Persons (NCOP)
Te situation of older women needs
maintenance remains fragile and more NO.22-3/99-SD dated 10 May 1999. Ministry
of Social Justice and Empowerment. Govern­
special focus in any discussion on connected to marital status.The unfet- ment of India. New Delhi.

unsatisfactory status of women’s
property rights.
Widowhood is intolerable be-

older persons. The high proportion of
widows in the 60+ group, the more
favourable female:male sex ratio in
the 60+ age group, the glaring differ­
entials in literacy and wages or earn­
older
ings between older men and
i
the
higher
morbidity
of
older
women,
women as compared to older men, the
differential access of older persons to
health care based on gender-all serve
to highlight the many points of inter­
ventions which should to be taken up
at policy level.
j____ ; t
Old age, as the policy document
Znnrate nart of
reminds us, is not a ‘ _‘
life.The policy views the life cycle as
a continuum, of which post-60 life is

tered right to will
,
independence.Care,SelfFulfilmentand Dig­
property which was introduced in the n-ty for 01der Persons (press advertisement).
Hindu Succession Act 1956 with Ministry of Social Justice and Empowerment.
of India. International Day lor
much fanfare has diluted the inherit­ Government
Older Persons. 1 October 1999. New Delhi.
ance rights of women. The continuing
Annual Reports. Ministry of Social Justice and
presence of the concept^ ot coP^rc^ Empowerment and the Ministry ofWclfare lor
nary too has affected her rights to the years 1994-95. 1995-96. 1997-98 and
Delhi.
-cxs inherited property. She has a 1998-99.
1998-99.New
Newueim.
access
•ioht to inherit, but her right to ask for The Project OASIS Report Submitted by the
°
i. Expert Committee forDevisingaPensionSyspartition
of property...
is subject to male
tem for India, Ministry of Social Justice and
approval and is not unfettered.
Empowerment, 11 January 2000. New Delhi.
Judicial attitudes and pronoun­ A Consultation on the Status of Women and
cements have led to women being ^^^1^3(18-20March 1999),Vardhc
considered incapable of managing Collective Vacha, Mumbai, 1999.
oroperty. The risht of a woman to re- conference Report on Widows in India (23__ ic house
n.!
lOQdl
1 ndian
InstitUtC
of ManagCside in her natal dwelling
is 24 March
iwh
Indian
Institute
of Management.
Bangalore.
also made subject by the courts , to her
The Himachal Pradesh Maintenance of Par­
an integral part. It does not view age being unmarried, while daughters who ents and Dependants Bill 1996.
60 as the cut-off point for beginning a are divorced, deserted or widowed are Report of the Independent Health Commission

20

crimination on account of their gen­
der throughout life. Patriarchy as a
system of male domination appropri­
ates women’s sexuality, labour and
fertility and keeps them subordinate.
This subordination takes the
shape of discrimination, disregard,
lv.luuv-m, ~
insult, control, exploitation,
oppres­
sion and violence—within
1— the family
as well as in the workplace and in the

Ageing
■w

otaUtesallye«lud«dl.„d=Ip.tna[-

■^53==-

chai norms. Thus the situation of older
women, intrinsically bound with their
ictal entitlements as well as their

India, New Delhi, 1997.
Murli Desai, 'Ageing of Women in Post­
Menopausal Stage: Need for InteT^nl,°n ’

not referto thisaspect at all.
Withoutattacking the root cause
of exploitation, which is women’s
unequal status in law, only cosmetic

30October-5 November 1999.
MaliniKarakal, ‘Ageing and Women in India .
Economic and Political Weekly. 30 October5 November 1999.

Ageism
VINAY KUMAR SRIVASTAVA

[I] spent [my] childhood playfully;
youthfulness sleeping;
cried at the sight of old age.
-Lines from a Hindi film song

In England, about two-thirds of all hospital
beds are occupied by those over 65. It is a huge
economic burden on the community to meet
the cost of retirement pensions and support
vast medical social services. Besides, a great
strain is placed on the younger generation to
look after them.
- Park and Park (1970)1
Dyallpur in Punjab is seen as becoming‘grey’:
this'greying-beingsynonymouswiththeeldot
-Ix. koma
’mspivps
erly
being loft
left behindtntoInnL
looknrfpr
afterthf
themselves
while the younger membersofthe family tread
distant lands for better opportunities. The vic­
tims are aged parents who. having spent their
life in bringing up their children, are ultimately
leftto fend forthemselves.
- The Hindustan Tunes (9 July 1999)

MY work neither involves working
with senior citizens nor on old age.
Like most students of social anthro­
pology, I am interested in kinship sys­
tems. However, my focus is more on
the rich (i.e., upper and upper middle
class) and elite strata of Indian soci­
ety as it has been grossly neglected in
the discipline with its concentration
upon the institutions of tribes and
peasants. An empirical study of kin­
ship systems begins with the most
elemental kin group, the family, which
forms the comerstone of human soci­
ety. Studies on the family begin by
explori ng the rules of descent, succes­
sion and inheritance of office, domes­
tic deities and ritual apparatus, wealth
1. J.E. Park and K. Park, Park’s Textbook of
Preventive and Social Medicine, Banarsidas
Bhanot Publishers, Jabalpur, 1970, 13th edi­
tion 1991. p. 328.

and other material appurtenances. It
is in the passage from the elderly to
their descendants that we look for the
operation of these rules.
Kinship deals, with the basic
facts of life: birth and death. Popula­
tions are replaced but cultural rules
and patterns of behaviour endure. The
old are replaced; the new recruited
and trained who, over time, get ready
to be replaced. The developmentallyoriented view of life is the pith of
kinshipstudies.
r

,

For the purposes of this brief
note, we look at the elderly popula­
tion, initially in the context of family,
and then move to other institutions,
of which the state is of tremendous
importance. This is our vantage point:
contextualizing old age and its bear­
ers in various institutions.
During fieldwork'in an upper
and upper middle class neighbour­
hood in south Delhi, I spoke at length
with some old people who spent
most of the time at home while their
sons and daughters-in-law, or daugh­
ters and sons-in-law, were away at
work. From these conversations I
learnt that age stratification is con­
comitant with ageism, a concept that
implies discrimination on the basis
of age categories. The maximum dis­
crimination experienced by the aged
was within the family. However, para­
doxically. it is the family, a ‘primary
institution ’ in Abram Kardiner’s words,
which can tirelessly fight ageism.
In April 1997, at a meeting of
Sandhya Jyoti, an all-Indiaassociation
of senior citizens, one speaker sug­
gested holding Mr Indiaand Ms India

SEMINAR 488 - April 2000

21

contests for old people. The point this
elderly c tizen’, as he called himself,
was endeavouring to make was that
the aged were not discarded people,
they were) ‘very utilizable and useful’.
Given tKe overarching emphasis
society ajid its institutions place on
youth, vitality and physical attractive­
ness,, old'er people tend to become
marginalized or ‘ invisible■’. ::
Many, oth­
ho
spoke
at
the
meeting,
felt that
ers wl
older people should be ‘brought into
the mainstream’. True, that none of
the speakers were in any position to
specify what that mainstream was, or
which social ingredients comprised
it. However, everyone intuitively knew
that the need of the hour was to make
older people more visible, ‘drawn cen­
tripetally’ , so that not only were their
needs and demands recognized but
that they could emerge aS a strong
interest sroup. The proposed Mr and
Ms India contest represented a sym­
bolic expression of the changing atti­
tudes towards old age.

has led to a population explosion of
older people. In the United States of
America/people above the age of 65,
who number 35 million today, will
double by 2030. So will those who are
85 plus, sometimes called the ‘oldest
■
old’, numbering about 4 million today,
’
It has to, for the ‘global experiment ’In Japan,
onerin six persons is over 65,
in life extension’ is underway.2 Certain and in a dozen years that proportion
demographic facts are on record. The will change to one in four. India’s eldlife expectancy of the ancient Romans eirly population (i.e., 60 years and
was 22 years; an average global man above), which in 1996 was 60 million,
today can expect to live for 65 years, is
i projected to rise to 76 million by
The lowest lifespan today is 38 years 2001 (i.e., 7.7% of the population) and
in Sierra Leone; the highest is in 113 million by 2016 (8.9% of the
Japan where a male is expected to population).5The global elderly populi ve for 76 and a female for 83 years, lation is expected to touch 612 million
Just 57 years ago, Japanese men could by 2000. Reliable information on
expect
pect to
to live
live for
for only
only 35.4
35.4 years
years and
and ‘centunonold’ (people living for more
women for43.6. The average lifespan than 100 years) is not available for all
in India today exceeds 62 years, which countries; however, their number too
I| has been steadily rising.6
in 1983 was around 52.
As a result of better nutrition, adin public health, improved ^.Kluger(1997:47).
vancesI x
.
----- -4. c.f. Kluger
(1997:52).
5. See th/advertisement inserted by the Min2. See S.K. Ramoo, ‘When You’re Old and istry of Social Justice and Empowerment,
Grey’, The Hindu, 18 August 1997; Jeffrey Government of India, in the national dailies
Kluger.'Can ScienceSlowtheAgeingClbck?’ on the International Day for Older Persons,
Time, 20 January 1997: Rick Weiss. ‘Ageing: 1 October 1999.
New Answers to Old Questions’, National
6. For instance, the number of centurion JapaGeographic, November 1997.
•

22

MeaYitime, there has been a
sanitation and myriad medical breakthroughs, the average human longe- steady decline in global birth rates. It
vity has nearly doubled in the last 100 is not only because of the ‘population
years. It will further increase: it may bomb’ that couples are encouraged to
triple, quadruple, or perhaps the very .have fewer children - the ‘one-child’
concept of lifespan may be elimi-norm adopted by China has been
nated.3 Human beings may live for- enforced punitively. Changes in gen­
ever, with death becoming an event der relations (especially the ideology
of the past. Bruce Sterling, a science of gender equality) and several culfiction author, in his book Holy Fire turally tolerated alternatives to tradescribes the process that transforms ditional institutions of family and
a 95 year old woman into a girl of 20. marriage (such as cohabitation, gay
In a complete cellular overhauling, families, staying single) too have
new genetic material is spliced onto contributed to decreasing fertility. It
the ends of each of herchromosomes, is observed that many married profes­
a technique which not only revives sional women prefer to remain childher youthfulness but possibly negates less; pregnancy^and child-rearing
often interpreted by them as an oner­
the concept of lifespan.4
ous burden that thwarts upward career
and
professional mobility.
The global increase in longevity

Ageing

1

1 •

1

1.1

’

. .

_________ _ — J

”

IVIodernity is inversely related to

fertility and the desire to discover
self-fulfilment in one’s progeny. This
ideology is most fully expressed in
the western
l.._
------ -----world;
—. its individualism
standing in marked contrast to the centrality otherwise accorded to large
scale kin bonds. An individual desires
to see himself achieve whatever he
sets his eyes on, ratherthan expect his
descendants to achieve what he has
not been able to in his own lifetime
CSelf-fulfilment, more than
L an indirec.
fulfilment through investmenttin
children, is what characterizes the
modem man.
A drop in birth rates has important repercussions for the elderly. In
proportional terms, fewer young and
middle-aged people will be available
to care for the older population in
the years to come. During my fieldwork in urban south Delhi I came
across many households that consisted of grandparents, parents and a
|one grandson. It was the grandson
nese has risen from 153 in 1963 to nearly 7400
in 1996 (Kluger 1997:46-7).

I

1

3

whowasexpectedtolookaftertheeldA synchronization of chrono- age. When the average life expectancy
erly. One may imagine the pressure logical age with social age results in India was 52, the retirement age
such grandsons experience. Many in foregrounding normative propo­ for central university teachers was
sons and grandsons, I learnt, sacrificed sitions like ‘girls should get mar­ 65; this remains the same despite an
opportunities for careerenhancement, ried before they turn 25’, or that ‘one increase in longevity.
especially those which demanded should retire at the age of 60’. In other
It is against the dialectics of
their geographical mobility, because words, activities are spread out acc- these two relations that we can under­
they had to look aftertheirold and ail- ording to the presumed conception of stand ageism. To recapitulate, it is in
ing parents and grandparents.7
the chronological age.
relation to younger and middle-aged
How the world will cope with a
citizens, and second, in the relation
rising elderly population remains to be ^^ne can easily visualise increas- between different age categories, that
seen. While not furthering alarmist
ageism makes sense. Ageism may be
arguments, it is clear that younger ing conflict in situations when a gio- defined as discrimination against peogroups will be entrusted with larger bal extension of chronological age is pie on the basis of their age. It is an
and graver responsibilities than now. unmatched by acorrespondingchange ideologymuchinthesamewayassexMany nations are likely to promulgate in social age. In Britain, for example, Rmundraricm
ism and racism. i()
laws requiring children, sons and/ the age of compulsory retirement for
or daughters, depending upon the des­ most men is 65, while forwomen it is To retire women at 60 and men at 65
cent principle recognized by society, 60; this despite the fact that women
to take proper care of their parents in outlive men by several years/ Many because ofaperceived decline in their
their dotage. Infringement of such European nations today favour a working ability and output is an exam­
laws will gradually become a serious reduction in retirement age as a pos- ple of the practice of sexism. To prooffence as the elderly population be- sible solution toever-increasing claim that people of a particular race
unemployment. In these contexts, the are endowed with lower intelligent
comes more ‘visible’ (demographi- unemployment.Inthesecontexts,the
cally as well as politically) and its beginning of old age coincides with quotient than others indicates racism,
problems multiply manifold.
retirement and is associated with Similarly, there are many stereotypes
particular kinds of welfare benefits, of older people. In Britain it is com^^ld age is a cultural construc­ such as provident fund, pension, leave monly believed that ‘most of the over
encashment, gratuity, and insurance sixty-fives are in hospitals or homes
tion, in much the same way as are the payments.
for the elderly; that a high proportion
other phases (‘vocations’) of life. For
When people retire at the age of are senile; that older workers are less
heuristic purposes, we have devised 60 (or 65 as in these countries), they competent than younger ones.’11 It is
concepts like chronological age, bio- are invariably healthy and can still likely that many of these beliefs might
logical age, psychic or mental age, work for long hours and under pres- havecometodominateourconscioussocial age, and many others. Since sure oftime. They can easily continue ness because the young and middle
these are our constructions, each of with the same job for another decade aged citizens felt threatened about
them relevant to a specific discipline, or so without any substantial loss of their future once they found that the
problems are likely to surface when efficiency. Retirement thus, creates coveted positions were being mono­
a specific categorization of age is social, economic, and psychological polized by older people. Such per­
soughtto be harmonized with another, problems for such individualsand ceptions are equally widespread even
Take for example chronological age quite often for members of their in those social situations where the
with social age; while the former is households.9 A conflict situation notion of retirement does not apply.
reckoned in years counted from the arises because of a clear mismatch like those relating to the world of arts
date of birth, the latter (social age) between chronological age and the and politics.
grades life in terms of activities an corresponding gradation of social
Robert Atchley rebuts many of
individual is supposed to carry out 8. Anthony Giddens. Sociology. Polity Press, the ageist Stereotypes prevalent in
from birth to death.
Cambridge, 1989,p.598.
English society. He points out that
9. See Herbert S. Parnes, Retirement Among 95% of people over 65 live in private
7. See Kumkurri Srivastava and V.K. Sri- American Men, Lexington Books, Lexington,
23
vastava. ‘When Peers are no More: Some Mass., 1985; John van Willigen. Gettin 'Some
RamblingThoughts on Old Age'. The Anthro­ Age on Me,The University Press of Kentucky, 10. Giddens.op. cit, 1989,p. 600.
pologist 1 (1), 1999, pp. 25-35.
1989.
11. Ibid.. 1989.
SEMINAR 488 - April 2000

' ordwellings andj not in hospitals
homes for the elderly. Less than 7%
of those over the age of 80 show pronounced symptoms of senile degen­
eration. The working ability and
attendance records of workers over
60 are often superior to those of
younger age groups.12 Moreover,
1------many tasks require experience for
theiraccomplishment. In many cases,
younger workers need to be guided
by their senior colleagues. In a soci­
ety marked by individualism, potential hostility between the younger
and older age groups can be mediated
by pointing out that their relationship is analogous.to the one between
the individual and culture; the former
ishiah in energy, the latter in information. The young are the repository of
energy, theoldofknowledge;asynergism exists between the two similar
to the interdependence between the
individualandculture.

of older people would increase the joint family was far from being comgeneral level of social tolerance. Ben- mon in all layers of society; that even
■ moment monopolized
•' ”byi in the landed, propertied groups, it
efits at the
the young and middle-aged might per- was not prevalent at all points of time,
haps become moreevenly distributed Afterall the family, likeany other insin the future. At the moment, people titution, is a process in time.
in these age groups have a monopoly
Equally, it is wrong to assume •
overeducation,
work,
power
and
mathat
older
persons were
always res- -----,
...
terial rewards. A more even distribu- pected and honoured in traditional
tion of these, from which older people societies. Emile Durkheim, the French
can draw just as much profit as sociologist, in his study of the socioyounser individuals, would be in the logicalcausesofsuicide,documented
interests of social justice.’ For bring- cases from societies where the elderly
ingintoexistenceajustsociety,arevo-- not needed for the tasks of production
lution in ethical and moral dimensions and other work, were obliged to kill
is imperative, and the family can play themselves. Durkheim called this an
‘obligatory altruistic suicide’.15
-a big role in heralding it.

The
problems of the old are usuTheproblemsoftheoldareusually expected to accentuate when lEven the concept of renunciation,
joint families and households break
down. This
This argument is
is similar
similar to
to the
the so central to the understanding of
one put forward by the Zagreb anthro- Hinduism, was probably devised as
pologist in Lawrence Cohen's book, a way to keep the elderly out of the
who
who believed
believed that
that since
since the
the NorthNorth- mundane society, dominated by the
Eastern Indian hill community he had young and middle-aged. Perhaps at
researched did not have ‘bad families’ the latent level, renunciation was an
any activist groups of older (it had joint familiei) there was no ideological instrument to separate
citizens have come into existence to senility, nodementia, no Alzheimer’s, the young and middle-aged from the
elderly, so that the people on their
combat ageism in theWest. Astheold no ‘crazy oldies’.13
way out did not meddle with the affairs
form a larger proportion of the popu­
of
the world which were i he prerogalation they are likely to acquire greater
•^^uch views are normally for- lives of the people in the vocation of
political influence. In the US they
have already created a powerful poli­ warded by those who base themselves the householder ^rahastasrama).
tical lobby. Similar developments on a middle class picture of society Scholars writing on non-renunciation
have shown the crucial importance
are visible in Britain. The scenario is and take for granted that something
of the householder (the young and
resembling
a
joint
family
was
comset for a manifestation of antagonism
toall strataoftraditionalsociety, the middle-aged) in perpetuating the
between the younger and older citi­
economic and social life of the com­
zens. One of the questions raised by In this they are mistaken. Social
an article in the National Geographic anthropologists and sociologists munity.16
It is wrong to assume that the
(1997) was,‘How would future gen- have abundantly shown that the emererations fare in a world where the gence and social reproduction of the position ofthe patriarch, hononfica y
and
elderly - no matter how beloved — joint family is predicated on specific called
c------ karta, of an upper caste
__
conjunctionsof
ideological
and
mateclass
joint
family,
exemplified
the
refused to depart?’
rial
factors.
14
Economic
and
ideational
typical
pattern
of
a
traditional
society,
Growing ageism can be checked
Ethnographers have documented
by encouraging sociological meas­ inequalities characterized all tradi­
ures and strengthening institutions. tional societies. As an institution, the
____________
15. Emile Durkheim. Suicide: A Study in
Giddens (1989:600) writes: ‘Aredefi­ 13 Lawrence Cohen. No Ageing in India: Sociology. Routledge and Kegan Paul. Lonnition of the value and contribution Modernity Senility and the Family. Oxford don. (first published 1897.1952ed).

M

24

12. Robert Atchley,
Forces and Ageing.
Wadsworth. Belmont. 1985; Also see Giddens.
1989. pp. 598-600.
Ageing

University Press. 1998. pp. 16-17.
14 See A M Shah. The Family in India: CriticalEssays. Orient Longman. 1998.

|6. TN. Madan. Non-renunciation: Themes
and Interpretation of Hindu Culture. Oxford
University Press, Delhi. 1987.

I

numerous cases of maltreatment of
the old people, in verbal and physical
terms, in villages which stereotypically are supposed to mete out the best
treatment to their elderly population,
Heise et al. have documented many
cases ofelderabuse, especially of wid­
ows, in the US (the only country for
which such data is now available).17
During fieldwork with Rajas­
thani villagers, I routinely encoun­
tered situations where the elderly were
abused forfailing to do an assigned task
to the satisfaction of others. They were
often sternly admonished by their
descendants to mind their own affairs,
Little interest was paid to theirsuggestions. Often they were interrupted and
told to be as pithy as possible. No wonder, wheneverthey found a listener (a
role best performed by social anthro­
pologists and sociologists), narrations
of their life-event and stories were
literally ceaseless.

^^therwise. the old people were a

‘muted lot’, to borrow the apt words
of Edwin Ardener - their tongues
were tied and 1 ips pursed because of
the structure of dominance. It was
not that they did not speak, or put forward their point of view, but that they
remained unheard. And if bed-ridden,
their sons and daughters-in-law who
served them grudgingly, routinely
cursed them for their predicament,
their karma. The glorification of the
aged in traditional societies is per­
haps more of an assumption than an
ethnographically supported fact.
Even though most episodes of
elderly maltreatment take place
within the family, it nevertheless
remains the most important institution for initiating an ideational revo­
lution in society to effectively combat
ageism. The role of the family in

!

17. L. Heise etal.. Violence Against Women:
The Hidden Health Burden, World Bank Dis­
cussion Paper, 1994.

bringing up new generations of peopie is fundamental. Many values and
ethical norms are inculcated in the
young by the family. Children are the
personalization of the sub-culture of
the family in which they have been
socialized. To combat ageism and to
provide its critique we need to inculcate a view of life as a process; the
family can play a central role in dis­
seminating this ideology.
The proposed National Policy
for Older Persons highlights (z) the
need to regard life as acontinuum and
the age after 60 as another phase; and
(zz) the need to create an age-integrated
society with strong bonds between
different generations and thereby
create conditions suitable for the elderly to stay with their families. Both
these aims can be best realized with
the active intervention of the family.

q

■^^tronger bonds between genera­
tions can be created not by the meas­
ure of fiat, in the sense of making
senior citizens press legal claims
against their children for not taking
adequate care of them in their old age,
but by bringing about endogenous
changes. The desire to take propercare
of one’s parents and grandparents
should emanate from within, from a
particular ethical (i.e., human) viewpoint, instead of being imposed and
sanctioned from outside
‘Within’ changes carry convic­
tion. Thus the conditions suitable for
the elderly to stay with their families
are not premised on a utilitarian model
of a good Samaritan, baby-sitting and
policing the household, answering
telephone calls, and handling domestic chores. Kinship, love and affection
should haVfe priority over economy,
utility and profit. Within this frame­
work, I keep my mother with me be­
cause I love her and not because she
takes care of my children. She baby­
sits, for she is a member of the house-

hold and not the other way round. The
potential of the elderly has first of
all to be acknowledged in the family.
It is within the family, rather than
through the state, that we can visual­
ise a possibility of ameliorating the
condition oftheelderly.

Io sum up, the definition of the con­
cept of age is largely dependent upon
the nature of the discipline; hence we
speak of the biological, sociological
and psychological conceptions of age.
Old age is also culturally constituted;
its connotation in a simple society may
be qualitatively different from that in
acomplex modern society.
In recent years, older people,
who now constitute a large proportion
of the population of the industrial
society, have started to press for grea­
ter recognition of their distinctive
interests and needs. The struggle aga­
inst ageism is an important aspect of
this development. The family, as an
institution, can play an exemplary role
in fighting against ageism, and in the
realization of many aspects which
are now enshrined in the proposed
National Policy for the OlderPersons
by inculcating a developmentally
oriented view of life in succeeding
generations.
One possible way of bringing
the elderly population into the main­
stream of society is through furthering
an ideological revolution at the level
of family. By focusing on the family,
the intention is not to undermine the
sociological importance of ‘family­
like’ institutions, such as homes for
the aged. However, we should not for­
get that a move to these homes may
amount to announcing to the world
that an inmate has produced unfilial
children. No older person would like
to make his children a butt of ridicule.
I learnt this from my conversations
with the old people in south Delhi and
rural Rajasthan.

25

SEMINAR 488 - April 2000

... ....... .

•f

Social ageing in
India and America
JOHN VAN WILLIGEN

'In India we have the joint family system,
in the West you have old age homes. India
is better.’

y

y
1

•i

/

I?

26

Ageing

I have completed two very similar
‘ ,
research projects on social ageing,
one in America and one in India. My
research work involved going back
and forth between ageing research in
both the United States and India for
about the last 12 years. During this
period I participated in scholarly discourse about ageing, the meaning of
social research on ageing, and overall
societal trends.
In this essay I will discuss some
perceptions formed by these experiences. Many of my opinions derive
from the juxtaposition of what I learned from those two research experi­
ences and the way that Indian and
American people regard each other
in terms of ageing. I have been struck
by the way Indian people perceive
the situation of older people in India
I----and the United States and ho w they
evaluate that difference. The opening
quote represents one viewpoint that

I have frequently heard when inter­
viewing people in India. I discuss
some of these contrasts, including In­
dian perceptions of the United States
compared to my perceptions of the
United Sta^s and my view of Indian
self-perceptions as they compare to
what actually seems to be occurring to
olderpeople in India.
Much of this relates to my
trying to figure out the reality and
dynamic of the joint family and old
people in India. Most Indian researcn
scholars have a view about ageing in
the United States which is suffused
with stereotypes, and if not wrong
only partially true. More often than not
this is conveyed through smug expressions of India’s ‘moral superiority’
and ‘spiritual development’ in con­
trast to the ‘materialism’ and ‘moral
decline’ofthe West.
The other side of the equation
involves understanding the conceptions westerners have, both about the
Indian family as a place for ageing and
their own relations with their parents,
Most westerners tend to romanticize

V /

<CJ

I

n

J?

Sunday mornings where they would order to support themselves. Old
listen to the preacher offer his or her people would often talk about the lack
views concerning the moral implica- ofjobs for the youth rather than prob­
tions of the congregation’s behaviour lems more associated with their age
and how they could ‘grow in Christ’. mates. The community represented a
The
‘religiousdiscourse’ would inva- kind of demographic shell.The popuIn India, with some limited excep­
riably end with an invitation to the lation wasold.
tions, ageing researchers place a congregants to‘publicly declareChrist
high value on the joint family. I always as their saviour’ and to submit to the
Just as I was finishing the book about
thought that they do so uncritically, sacrament of baptism.
Very much going against the grain.
Further, there was little tend- my Kentucky research, I got a Ful­
K. G. Desai, now retired from the Tata ency toconspicuously display wealth. bright lectureship for India. This was
Institute of Social Sciences in Mum­ After I got more familiar with the com- not totally out of the blue as I had stu­
bai, once wrote that the joint family in munity, I could observe groups inter- died Hindi while a graduate student
India represents a forced choice, made acting which would include people the in anthropology and had intended to
because of inadequate retirement in­ local equivalent of crorepat is as well do my dissertation in India, although
come that necessitates pooling, and as those who were more or less poor I never was able to. While lecturing
expensive housing that compels shar- tenant farmers. They dressed the same about applied anthropology at Delhi
ing quarters. He concluded that if peo­ and talked the same. Distinctions University, a faculty member in psy­
ple had adequate assets they would based on wealth were subtle and chology. N. K. Chadha, suggested
expressions of materialistic values that we collaborate on a research
live in nuclear family households.
In contrast to Desai’s view, were very subdued. Communicating project. As I wasjust in the laststages
based on my research and the experi- equality represented an important of completing the Kentucky book. I
ence of living with a three-generation value. The image of American mate­ suggested that we do a similar study
family in Delhi for many months, I rialism would be challenged by the in India. It was a good time for such a
came to the conclusion that a joint experience of doing research in a place project, as there had been little rese­
arch work on older people at that time.
family was a good situation within like this,
There was increasing unease about
which to grow old. It has been my
the apparently rapidly ageing Indian
experience that people are, for the ■W"
I
he
situation
of
older
people
in
this
population. Now, ten years later, there
most part, helpful and loving and that
there were a lot of interesting things county was coloured by demography is a lot of research and many publicagoing on. It was a good place to be very and migration. The percentage of tions, mostly by psychologists.
The neighbourhood we studied
old and very young.
older people was high. No broadMy first social ageing research based, fertile, population pyramid was established in the early 1950s,
experience was in the United States. here. It was more like acolumn. While mostly by people who had migrated to
I studied rural people in a county near some seemed to attribute the age struc­ Delhi from the Punjab during Parti­
where I work at the University of Ken­ ture to increased longevity, it was tion. The circumstance of the neigh­
tucky. Many families were involved more a matterof out-migration. Many bourhood’s creation also relates to
in farmingand there were no industrial younger people were forced to move the population being mostly well-off
jobs in the county. The annual produc- away because of limited employment business families. One effect of this
was that most households consisted
tion cycles of tobacco, corn, hay and and the relatively poor income pro
beef cattle had an important impact vided by agriculture. Because of this of joint families. It was interesting
on the flow of life. Many people had the average age of the county was high for me to deal with a sample in which
active religious lives and were con­ and getting higher. In this rural Ameri­ there was such a big commitment to
cerned about their spiritual develop­ can community, as everywhere else it joint families. Chadha and I found
ment, which was important to them. seems, demography is an important that over 80% of the households
When Indians spoke of the materi- factor structuring the nature of lives of were joint, mostly three generation, or
alism of the West, I automatically ageing people. Often when we inter- formed of families of brothers. Had I
thought of the people I researched in viewed olderpeople they lamented the limited my understanding to only the
rural Kentucky. It wasn’t that way at fact that theirchildren and otheryoung research from this study, I would have
all. They would attend church most people had to leave the community in concluded that joint families in India

the Indian joint family while being
fairly self-critical about their ability to
care for their parents.

SEMINAR 488 - April 2000

..........

27

joint families are increasingly ‘just (Rs 800,000-1,000,000); using influence and connections to get their chil­
living together.’
In fact, every once in a while I dren jobs; caring for grandchildren;
still get a glimpse of the ‘real joint fam­ inviting the family forSunday dinner;
ily’ pattern marked by robust patriar­ nursing older relatives when they get
chal authority and large size. It seems sick;,paying for their children s mar­
riage; and making efforts to have peo­
■ he idea that the joint family is dis- (clear that inspite of large co-resident
in the present, there is ple attend church together, among
appearing is a widespread one. Most households
I
many otherthings. In Kentucky there
books published on ageing topics in substantial difference with the situa­
is even a tradition of having family
India assert it. It has come to be a kind tion in the past: more individualism, reunions for those that liveelsewhere.
of standard introduction expressed less pooling or sharing of assets, less
In short, they express in strong terms
as a forgone conclusion. This is not gender inequality. Maybe it is true a commitment to each other’s welfare,
to say that there is much high quality that mere co-residence is not that it’s just that they don’t live with each
evidence that this is true; it’s just that important and that the issue is some­ other, especially after they graduate
many people lament the joint family s thing more like familial love, coopera­
from high school.
demise. The ‘breakdown’ in the joint tion and commitment. Ironically,
family system is a recurring theme? ' Indian interpretations of the American
They don’t lament this. ‘He still lives
I agree with Lawrence Cohen, an situation seem to focus on the Ame­
American medical anthropologist rican pattern of nuclear household
• • ■his
• parents
‘ is seen as some
who has called the ‘decline of the joint residence irrespective of issues of with
kind
of
low-level
character flaw for
family’ the central narrative of Indian commitment, familial love and coope­ anybody, especially a boy past high
ration. American families too exhi­
gerontology.
school. I recall that when my parents
However, there doesn’t actually bit familial love, cooperation and
were alive they expressed the central
seem to be any research that conclu­ commitment; it’s just that they don t
live in the same houses or even in the American ageing narrative; and often
sively demonstrates that the fre­
talked about not being a burden.They
quency of joint families is today less same city.
were proud of the tact that 1 did not
in India than in the past. On average, ■
have to support them in their old age.
older Indians live in large households I thinkco-residence'isconfusedwith My father often teased me by sugcompared to Americans. I have seen family commitment. In my view Indi- gesting that they would move in with
citations from national surveys indi­ ans tend to look at American families my wife and I. They accomplished
cating that only 6% of the elderly in tPrm. of the meaning they attach to their independence, of which they
population of India lives alone or in terms of the meaning they attach to were proud, through their savings
with non-relatives. A comparable the co-residence pattern found in and social security. As they got old it
statistic for Americans from good America. Families who don t li ve toge­ was more likely that they would se
ther mav in fact be quite committed
national level data is just over40%.
me money rather than the other way
Statistics from India about co­ to each other. My wife and I see or talk around. As their health declined, my
residence indicate that joint family with our married daughters about sister and I began to do more and more
living is still common for old people. once a week. We have no sons. When for them. Our last act of caring was
an acquaintance from India suggested iwt
-I probably overrate the importance
that I must be lonely because I don’t burying my
sra^s in
* a cem­
of co-residence rather than family
etery
surrounded
by
family
members
attachments, possibly because it is see them more frequently, I recall from all over America.
relatively easy to study who lives with thinking facetiously, ‘we use email’.
The two communities saw fami­
The Kentuckians whom I stu­
who and more difficult to investigate
lies in very different temporal frame­
family attachments. I assume that died are family-oriented, yet they works; existentially the Kentuckians
when people say that the joint family tend to live in nuclear family settings and the Delhites present an interesting
is disappearing, they are referring to or alone. What do I mean by family point of contrast. Given the religious
orientation? They actively maintain
something beyond ‘mere living toge­
beliefs found in the Kentucky commu­
ther’.! imagine that the way power ties of love, respect and support nity, people conceived that family
28 and authority are structured in the in spite of not living together. They groups could be together for eternity.
household is an important part of do this by financing their child­ As Christians, they saw themselves
ren’s education beyond high school
the transformation and that people in

were robust and important. However,
even in this setting, people said that the
joint family was declining in impor­
tance or decreasing in frequency.

T

Ageing

going to heaven as individuals and
being in contact. They spoke of seeing
each other on the ‘other side’. In fact,
for some this represented a motiva­
tion to encourage younger family
members to take up religious life and
to tend to their spiritual development
and salvation.
\/\/hile I have found Indians to be

expressive about the life of older
people in America, Americans tend
to have fewer opinions specifically
focused on the situation of older peopie in India. If anything the tendency
is to think of India as a country of
young people while ignoring the large
and rapidly growing older segment of
the population. This relates to percep­
tions and misunderstandings about
the implications of the differences in
lifeexpectancy between thetwocountries. There are those who confuse life
expectancy with life maximum. This
is a naive but common view. Beyond
that is a tendency to take a romantic
view offamily life in Asia. Americans
see India as a place where older people
are treated with respect and honour
thrcomextof extended families,
in

Importantly, these romantics ignore
the fact that structurally these families
require a patriarchal bias. Power and
wealth is concentrated in the hands of
males - fathers and sons - and that the
lives of women can be very restrictive.
It has been my experience that
people in India closely associate
nuclear family living arrangements
and loneliness. I do think nuclear
family life increases the risk of social
isolation generally. At the same time

loneliness is not a necessary outcome
of a nuclear family based life strategy.
In the India research we found that
those who lived in nuclear families
usually had more ties with people outside the household. I suppose you could
say that they compensated for their
somewhatdiminished social situation,

What do the Americans do?The
view communicated by the opening
statement that somehow the American
‘old age home’ is equivalent to the
joint family is inconsistent with reality. India may well be a better place
to age socially, but in America most
old people don’t live in ‘old age
homes’. The percentage is actually
quite small. About 5% of the popula­
tion 65 and over live in what are cal led
nursing homes in the United States.
■
The nursing home population is old.
Jointness requires wealth. It is quite three out of four are 75 years or older,

In fact their overall social network,
including household ties, was slightly
larger than of those living in joint
family settings in the neighbourhood.
1 found that the average size of
older people’s social network in both
Delhi and Kentucky are identical. The
Kentuckians lived in small house­
holds, often alone, while the Delhites
mostly lived in joint family house­
holds.

clear that joint families are not as A large portion of the population is
strong or frequent among poor people women. 34% of nursing home resi­
and landless rural people. It is also dents are women 85 and older. People
related to the economic strategy that in American nursing homes are chro­
the family uses. Jointness is less nically ill. They receive nursing care,
common among the salaried class I think Indian old age homes are
like government servants. This is what something like what Americans call
the ageing research literature shows ‘assisted living’. These are fairly com­
clearly. I always think of this when an mon. Usually this entails all the resiIndian colleague makes the‘you have dents eating together and perhaps
old age homes we have joint families’ benefiting from some sort of social
statement. (Only a certain percentage programmes and outings organized by
of people live in these kinds of fami- the institution.
lies. Certainly if youi are poor there
is a greater chance that you will be The number of persons living in
socially isolated. This is also apparent
in certain kinds of upper-middle class old age homes in India must be very
families. I even learnt that the kind of small. HelpAge India s 1995 national
household you live in largely depends directory of old age homes in India
on what kind of a neighbourhood based on extensive national survey,
you live in Delhi. For a while I rented found only 12,702 residents. At the
a flat in a better south Delhi neigh­ same time it showed that the number
bourhood and learnt that better-off, of residents was increasing and that
older people, mostly women, lived there was a national shortage of beds,
alone. The wealthy and the poor share The distribution of old age home beds
is highly variable from state to state
certain qualities in this regard.
Jointness requires a patriarchal in India, reflecting underlying demog­
raphy. The relative availability is
social structure. The key to a joint
• • - in the South where
family is the capacity to^capture the much• ■higher
love and attention of daughters-in-law. populations have begun the demo­
to lower fertility
In America there are no^daughters- graphic
’ transition
‘
*
and
lower
mortality.
When one looks
in-law in the Indian sense. The ‘joint
at
the
distribution
of
this problem,
family set up’ is contingent on valuesone
tends
to
think
in
terms
of the pri­
laws-practices that help men capture
macy
of
demography.
At
this
point
the labour of women, especially dauwe
can
assert
the
‘
demography
is
ghters-in-laws and have it appear
not
destiny
’
mantra,
common
in
the
morally good.
SEMINAR 488 - April 2000

■■

29

political action circles around ageing
in the United States.
Further, some say that the pro­
joint family rhetoric represents a
denial of the emerging reality which
keeps service providers and policy
makers from working aggressively
on the welfare problems of all older
people. Areliance on the idea that the
joint family will take care of older
people would be especially hard on the
destitute specifically and the poor
generally.
We are largely forced by circum­
stances into certain patterns of arran­
gement of social life. Our values and
self-concepts fit our circumstances
only with considerable lag. Both in
India and the United States there is a
tendency to view this re-arrangement
of domestic affairs as a kind of moral
crisis rather than a somewhat inevi­
table fallout of demographic change.
It appears that family structures
in India and the U.S. may be converg­
ing. As India’s age demography trans­
forms toward the pattern found in
more heavily industrialized countries,
the situation of older people will con­
verge even more. India may well be on
its way toward the kind of social cir­
cumstance experienced by older peo­
ple in industrialized countries.
An ageing policy based on the
idea that the joint family will sustain
the needs of older people is problem­
atic for these reasons: (/) large seg­
ments of the population do not have
access to joint family lite; (//) the joint
family requires a high extraction of
women's energies who are often not
vested in family property; and (in) the
family may be declining. There needs
to be a more objective assessment of
the situation of older people in order
to anticipate societal needs in a reason­
able way. This includes an objective
understanding of the demography of
30 age and the conditions of ageing for all
segments of society as opposed to the
reliance on wishful thinking and myth.
Ageing

Ageing pains
■SMITA KISHORE-

AGEING is both a universal and
a natural process. It is a change in
demographic structure, a rise in the
proportion of the aged population as
compared to the overall population
that has made them a highly visible
section today. The United Nations
declared the year 1999 as the Inter­
national Year for Older Persons; the
Indian government announced a Na­
tional Policy for the Aged. Popular
magazines, newspapers, radio and
televisions have write-ups and pr
grammes on the aged. The problem
has now entered centre stage.
The media, however, has its
own 1 imitations and is able to provide,
at best, a broad picture and at worst a
homogenized perception of the aged.
This paper based on fieldwork carried
out between 1995-1997 in a north
Indian city, attempts to capture the
voices of the aged themselves. It is
an effort to understand how the aged
perceive their own situation.
This paper focuses on the mid­
dle class, and within the middle class
the retired professional. A great deal
of debate has centred around the exten­
ded family versus the nuclear family,

I

but little is available on the everyday
aspects of family life in modem India,
An attempt is therefore made to
present the narratives of the aged and
to capture the shifts in their daily lives.

■T"
■his is not to suggest that the problems of the urban middle class aged
are universal. I make this point because of the sharp vertical and horizontal divisions that mark Indian
society. Though the middle class
forms but a small proportion of the
overall aged population, it is not only
a dominant section, a reference model
for society (though not always), but
is also a section that has undergone
dramatic socio-economic changes in
recent decades.
The middle classes have experienced greater social mobility in their
own livesascompared to theirparents.
Their children too have tended to
break away from traditionally defined
ways. A desire for upward mobility
and an emphasis on education has
meant, for many, a migration of children to bigger cities, both within and
outside the country. They also constitute the first generation retirees who
are trying to work out new norms and
behaviour patterns. Further, they are
characterized by reflexivity, that is.
they think about and discuss their
problems. This paper confines its
attention to the changing nature and
quality of relationships in the family
and the implications this has for the
urban middle class aged.
As Shah1 points out, this is historically a modem and rapidly growing
section among whom the institution of
joint household though strong in the
past is now becoming weak. It has
been under the maximum impact of
the ideology of individualism. It is
articulate and makes its presence felt
1. A.M. Shah, The Family in India: Critical
Essays, Orient Longman, New Delhi, 1998,

pp. iG-n.

in the media, the bureaucracy and in preferred the extended modified fam­
the learned professions. It tends to ily. Sussman refers to this desire of the
perceive its problems as those of the elderly to be close to relatives but not
entire society.
with them as ‘intimacy at a distance’.4
Though many studies have An elderly person expressed this
pointed out the role of the family for clearly: T feel it is better to have an
the elderly population, it was only dur- independent household. I prefer the
ingmy field study that I understood its idea of spending weekends together
importance. This is not to deny other with the children and have a healthy
important facets related to the issue of relationship, rather than live together
ageing, but that family roles and rela- and have ill-feelings towards each
tionships are fundamental factors other.’Yet another stated: T feel it is
affectingtheirdaily lives as they pro- not the quantity but the quality of time
vide a meaningful social role and emo- spent together that really matters.’
‘Living in the joint family is no guar­
tional satisfaction after retirement,
In recent decades there has been antee that one is taken care of... val­
a general debate about the changes ues have changed, joint living may
taking place in the institution of the sound good but it may not be so rosy,
family with sociological literature2 Living independently does not mean
talking about the demise of the exten- that the love, affection and care facded family, earlier the sole caretaker tors have disappeared.’
‘As a result of education, eco­
of the aged, and its replacement by an
unstable nuclear family. Of late, this nomic independence and changing
understanding has been criticized by values there may be conflict between
those who argue that the concept of an the younger and older generations
isolated nuclear family represents regarding small things like methods
more fiction than fact. Without under­ of cooking, preparing the menu bet­
estimating some changes in struc- ween the mother-in-law and daughterture, it is more important to look at in-law. So it is in fact better to maintain
the changes taking place in the func- a nuclear set.’
tion of the family. The first part of the
paper looks at the changing nature of There was agreement that it was
lived relationship with children, while
the second dwells on the relationship difficult to get along with the younger
generation because of their different
between the spouses.
ways ofthinking and doing things. One
response was: ‘Everything said and
first look at the relationship of the done... there does exist a generation
retirees with their children and their gap. But if elders keep their mouths
participation in various aspects of
Destiny, Harper, New York, 1959; A. Ross, The
daily living. Most of the retirees in this Hindu Family in its Urban Setting, Oxford
study lived in a ‘modified extended University Press,Toronto, 1961.
family’3 where families, though spa­ 3. A.C. Kerckhoff, Nuclear and Extended
tially dispersed, score high on contact, Family Relationships: Normative and Beha­
Analysis, in E. Shanas and G. Streib
interaction and change. Although viour
(eds). Social Structure and Family: Genera­
many of them were positive about the tional Relations, Prentice Hall, New Jersey.
concept ofjoint living, in practice they pp.93-112.

I

2. E.W. Burgers and H.J. Locke. The Family,
American Book, New York, 1945;T. Parsons,
The Social Structure of the Family, in R.N.
Anshan (ed), The Family: Its Function and

4. M.B. Sussman, The Family Life of Old
People, in R.H. Binstock and E. Shanas (eds).
Handbook of Ageing and Social Sciences,
Van Nostrad Reinhold Co., New York, 1976,
p. 222.

SEMINAR 488 - April 2000

31

the baby-sitters are very expensive selves. I feel that as soon as a person
and also where can one get homely retires he should take a back seat and
care by paying.’ Some felt that: ‘You accept a passive role if he wants to
take care, give yourtime, energy, love. maintain even a little bit of respect. ’
After all they are your children. Still
you can hear comments of dissatis­ ^^thers expressed their limited
faction. It really hurts. But what to
role in decision making: ‘No, we don’t
The frequency of visits was higher do... after all we are parents.’
When quizzed about the degree decide on anything except for my wife
and myself. My children come and
during the festival seasons and in case of agreement on various issues, most
inform us about their choice and we
of an emergency. Though mutual, the retirees felt that prior to retirement
passively agree. After all, what is the
retirees clearly preferred that their their children tended to either agree
use of showing annoyance except for
children visit them rather than the with them or preferred to keep silent
troubling yourself and disturbing the
other way round. They also wanted the in the face of disagreement. But after
peace within the family.’ Most of them
frequency of visits to increase, though retirement the attitude changed with
many of the children have settled ,, discussions and conversations with reported giving advice only wher
children usually resulting in heated asked to since most of the time then
abroad.
concerns were not taken seriously.
For some, their children’s arguments. It was the aged who tended
‘See, you put in so much of effort and
achievement was a source of pride: to compromise even on small issues
pain
to think about them, after all
‘My son is brilliant. Since childhood like choice of TV channels, what
they
are
children. But what you get in
he was of an independent nature. He to eat for lunch or dinner. This com­
return
is
humiliation. They turn a deaf
got selected in one of the topmost uni­ promise, however, was not without
ear
and
act
as if they know the ins and
versities in the States, did his Masters resentment: ‘Just because one is old,
outs
of
everything
and need no advice.’
in business administration from there one is expected to compromise on
T advice only when it is specially
and is now placed highly... we feel every small issue. My wife argues
sought
for, otherwise they are free to
proud of him. But at times we do miss that see you are mature, old, he is a
do
what
they think is right.’ Another
him... he is too busy to visit us regu­ child and so on... as if once you grow
felt
that:
Once your children become
larly. It has been almost six years since old you are’expected to lose interest,
economically
independent, get mar­
he last visited India. Though we do act as a saint.’
ried, have children, you should yourvisit him once a year, he gets very lit­
self withdraw from the role of advising
tle time to spend with us.’ Another jpKpart from the frequency of visits and directing, if you want the respect
one was despondent: ‘What can the
and quality of conversation, it is also to remain intact.’ ‘They think they are
younger generation achieve in this
important to understand the process the best judge and we are outdated^
country?’ But for another: ‘My daugh­
An important observation tu
ter is a very successful doctor in the of decision making and the advisory
role in the family. Before retirement emerge from the interviews was that
US. Why should I worry?’
’
> are increasingly
However, they admitted to feel­ it was solely the prerogative of the married daughters
an
important
role in taking
ing lonely and sad because the chil­ bread winner but after retirement it playing
care
of
their
old
parents.
In fact, par­
dren were so far away and wished that is more a matter between son and
ents
are
happy
to
accept
the help of
they stayed somewhere nearby. wife and does not extend to them. The
daughters
rather
than
sons:
‘Earlier
Clearly a desire for proximity, fear of young do not consult their parents we stayed alone, but recently my daudeciding on most matters.
actual living together and the safety of before
SomeTfVhe responses made this ghter and her family haf^ifted to
being able to boast about them at a distance was all present simultaneously, clear: ‘They don’t even bother to dis- the town. In fact, my daughter forced
her husband to get a transfer so that
Another comment reads as: cuss "With us, what are you talking
she could be near us. From that time
‘Both my son and daughter study about taking decisions. Husband
onwards she has taken over all my res­
abroad. Whenever my daughter or and wife decide amongst themselves ponsibilities. Though she stays almost
daughter-in-law are expecting we are and only inform us of their decision.’
Another felt: ‘They think they 10 kms away from the house, she
32 sentthe tickets beforehand. Both of us
’ ’i some­
are more rational, smart and well edu- drops in every other day with
go for a time period after which their
thing
she
has
cooked.
My
married
in-laws go for another six months... cated and hence can think for them- 1

closed, the situation remains in con­
trol.’Anotheronefeltthat: ‘Parents are
expected to make all the adjustments.
If we stay together we are taken for
granted, as if we don’t have our own
viewpoints.’

Ageing

son stays close by, but he hardly gets
time to visit us. Even when he does,
he is more like a guest. The only help
he can think ofextending is financial.’
They also stressed the point
that daughters not only provide care
willingly, but also receive every form
of help from parents as and when requ­
ired. As Jerrome suggests, besides
giving help daughters also receive
greater help than the sons, at least in
areas of childcare - the act of caring
means caring about as well as caring
for.5 It seems that the moral respon­
sibility, out of sheer affection and
love, falls more on the daughters than
on sons, which is also acceptable to
the parents.

j^kinother important observation

l

■W "W:

to emerge was that the elderly did not
like the idea of accepting financial
help fromchildren. Many of them saw
self support as important for main­
taining self-respect. ‘By God’s grace,
even after retirement, my economic
position is all right. Even now I have
the capacity to help my children in
times of need. I cannot imagine tak­
ing financial help from them at any
point of time. What will be my posi­
tion in the family as a dependant per­
son? I could not take that kind of
humiliation.’
When unwell the elders expect
help fromchildren, especially daugh­
ters, only to the extent that it does not
become a burden on them. ‘We take
care of each other... at times children
do come over, but one cannot expect
them todisrupt their daily routine and
take care permanently.’ Those with
children staying in the same city had
a more active give and take relation­
ship. However, nearly all stressed that
it was unimportant for children to
5. D. Jerrome. Intimate Relationship, in
J. Bond and P. Coleman (eds), Ageing in Soci­
ety: An Introduction to Social Gerontology,
Sage, London, 1990, pp. 185-195.

It was also interesting to see
how elderly couples adjust their lives
and routines after retirement. In most
cases a loosening of the rigid defini­
tion of ‘male work’ and ‘female work’
was noticed. In general the husbands
increased their participation in house­
hold activities, especially male oriented work like payment of bills,
buying grocery and so on. Although
most spouses appreciated the shouldering of household responsibilities
by husbands, an overindulgence in
the domestic space was often unwel­
come. T dislike the interference in my
f
domestic chores, especially com■ (or an overall understanding of ments like the room is not properly
family life, the relationship of the dusted, what should be cooked and so
retirees with their spouse becomes on. After all, I have grown old doing
important. The family in the West these things. I know my work well.
focuses on the husband-wife relation­ The problem is that there is plenty
ship, i.e. conjugal ties, while in Indian of free time and nothing really to be
society family means strong ties with done, no regular routine of going to the
children. However, this study points, office, so most of the time he tries to
towards a reaffirmation of spouse ties, interfere in my affairs. What does he
especially after retirement - a shift know of buying vegetables, what to
from consanguineous toconjugal ties. cook and how to cook? But he does
Though most of the spouses were not hesitate in giving directions and
non-working, but even for those who analyzing critically. This becomes
did work, retirement did not pose a more of a burden.’
problem as they continued with the
role of homemakers. But for almost
all women the retirement of husbands A^nother responded: ‘When it
was certainly seen as a period of cri- comes to kitchen work, especially
sis and transition. ‘No matter how cooking,Ipreferdoingitonmy own.’
positively one thinks, it is definitely Not only this, the usual answer to the
a period of transition. All of a sudden question. What do you do in your free
you are left with so much of free time time was, T don’t get even a minute
and nothing concrete to do.’
to sit and take rest... a woman’s work
Many respondents pointed to never finishes... at times even the
the problem of declining standards of whole day seems less.’
living and to reduced income: ‘Most.
Most of the spouses observed
of those retired are still capable of changes in their husbands’behaviour
working. A person who has enjoyed after retirement, although no pattern
power, prestige, status and comfort was noticed. Some of the responses
both at the workplace and home, is were: ‘He has become so critical of
suddenly required to adjust to the loss every small detail - be it family, chilin income, living standard... where dren, cooking or politics/ ‘He has
does one get a full-time paid servant become more helpful, giving extra
these days? Even they seem to be time to household chores. But then I
feel very bad seeing him do this work.
interested in govemmentjobs.

provide material help, but that they
ought to show affection, love, keep in
touch and give due respect. ‘Believe
me, although retirement has resulted
in reduced income, it is sufficient
for the two of us - me and my wife. I
believe that one should cut ones coat
according to the available cloth... the
question of help from children does
not arise. After all, it is the duty of
parents to look after their children, at
least financially. If there is anything
that I expect from them, it is respect
and care.’

SEMINAR 488 - April 2000

33

!

emotionally, for all their needs. It
was also interesting to notice how
both partners tended to become more
attached and devoted to each other.
T cannot imagine life without him.
We have had our share of fights, but
now we are so dependent on each
other. I know children are there to
Though the wives occasionally made take care of us but I guess nobody can
give the company and contentment
negative comments about their hus­ that a spouse can, especially in old
bands’ behaviour, they could not tole­ age.’ T think we are the best of compa­
rate any criticism or disrespect from nions, sharing every aspect of life in
theirchildren. ‘Yes, I understand that its minute details. I wonder what will
at times he gets irritated with the chil­ happen to him when I am not around.’
One of the retirees commented:
dren. I try to pacify him but I do not
like my children answering back. So ‘You won’t believe it, retirement has
what if he has retired, we are old. ' brought us closer. Earlier we were
Could we ever think of behaving like too busy with work and worrying
this with our parents?’ T do not like my about the children. Now that all of
children interfering in our matters. them are settled, we two are by our­
Even if he says something which selves to share every sorrow and hap­
sounds out of place, it is for me to cor­ piness together.’
rect but certainly not my children. I am
not ready for any disrespect shown to
I he devotion and love expressed for
my husband.’
In case of illness the main care­ each other in old age was incredible,
giving function was performed by possibly because of stability in life,
spouses. For most of them help is usu- companionship over the years, and
ally mutual between husband and shared experiences. As is well estab­
wife. Often they do not ask for help lished, during child rearing years the
unless compelled. An elderly woman marriage relationship is subordinate
commented: ‘My husband usually to the demands of children, and hus­
takes care of me when I fall sick. You band-wife tend to grow apart.6 The
know, he gets nervous even if I catch frequency of marital interaction re­
a bit of a cold and cough or tempera­ portedly increases in post parental
ture. It is only when our sickness years, particularly after retirement.
In old age, companionship and
requires prolonged care that we bother
ourchildren. Normally we do not ask the freedom to express one’s feelings
for help. Everybody, including our without being judged becomes the
children, has their own families, their most satisfying aspect of married
own lives. Why trouble them unnec­ life. This paper highlights the voices
of the aged in the hope that this ethno­
essarily.’
Little direct exchange of help graphic material may help in provid­
was observed except by spouses, and ing important clues to understanding
children in case of an emergency. the life of the aged.
Though both sexes showed an adjust­
ment to the post retirement years, 6. cf M.F. Lowenthal and B. Robinson, Social
Networks and Isolation, in R.H. Binstock
women were better adjusted than and E. Shanas (eds). Handbook ofAgeing and
men, and often tended to become more Social Sciences. Van Nostrad Reinhold Co.,
dependent on their wives, especially New York, 1976, p. 434.
In his service years, he never even
picked up a thing, everything was
ready.’ ‘Earlier he used to be so calm
and quiet and understanding but now
it is a different story. He gets irritated
so easily, he has become very shorttempered.’

34

Ageing

Demographic transition
ASHISH BOSE
THE 21st century will witness a
gradual transition to an ageing society
the world over. The process which
first started in low fertility western
societies and in Japan is now spreading to the developing countries ofAsia,
Africa and Latin America. Countries
like China and India will not only be
at the forefront in terms of absolute
number of total population, but also
in terms of absolute number of the
elderly (60+) population. In brief, the
long term impact of decline in fertility
and reduction in the size of family
will lead to a decrease in the population of childreir(0-14 years), which in
turn will push up the population in the
working age group.
Depending on the decline in
fertility and mortality rates and the
increase in the expectation of life, this
will lead to an increasing proportion

of the elderly after a time lag. A greying of the population is inevitable and
one must understand its implications,
Paul Wallace1, a popular writer, dramatically describes this phenomenon
as ‘agequake’. If we understand the
implications of ageing, agequake will
not descend on us unexpectedly like
an earthquake with death and destruction all around. Instead, we will be pre­
pared to face a world converging on
the elderly.
In his recent book, Understanding Greying People of India, Arun
P. Bali2 has put together a set of papers
1. Paul Wallace, Agequake: Riding the Demo­
graphic Rollercoaster Shaking Business,
Finance and Our World, -Nicholas Brealey
Publishing, London, 1999.
2. Arun P. Bali (ed). Understanding Greying
People of India, Inter-India Publications.
New Delhi, 1999, pp. 14-15.

SEMINAR 488 - April 2000

..........

35

________of an ageing population,, 2050 it is 326 million. These are frightcommissioned by the Indian Council implications
one cannot rely only on Census data ening numbers: an elderly population
of Social Science Research (ICSSR). <
He rightly points out that the elderly or for that matter, only on the demo- of 20 million in 1951 increasing to 326
are more vulnerable than younger per- graphic perspective. Specialised stu- million in 2050.
* If we look at the proportion of
sons to social and economic hardships dies and in-depth interviews of the
'* ’ > would provide better insights the elderly to the total population from
because, ‘in the process of develop- elderly
absolute numbers, we find that in 1951
ment, poor sections lose ground in than a statistical approach. Never­
it was 5.4% of the total population
relative and perhaps also in absolute theless, one does need a statistical
whilein 1991 itwas 6.7%. According
terms.*'This may mean that apart from account of the elderly for policy to the Registrar General’s projections,
an increase in the elderly population, making, planning and specific programmes to help the elderly through the figure will be 8.9% m 2016.
the population of the elderly poor will
governmental as well as non govern* According to the United Naincrease.
mental efforts. The object of th is paper tions projections, in2000, the elderly
A comparative account of
the elderly in India is presented by is to give some highlights of the emerg- will account for 7.6% of India’s popu­
S. Irudaya Rajan and his colleagues3 ing demographic scenarios based on lation . By 2025 the comparable figure
in another recent publication, India’s the latest data generated by the Cen­ will be 12.7% and by 2050 it will be
Elderly: Burden or Challenge? They . sus of India, NSSO and relevant 21.3%.
* It should be noted that the pro­
point out that while the increasing United Nations publications.4
portion of 60+ female population is
numbers of the elderly is attributed
invariably higher than that of the male
to demographic transition, ‘their In 1991, when the last decennial Cen- population. According to the UN prodeteriorating condition is considered
sus was undertaken, the population of jections, in the year 2000 the 60+ male
as the end result of the fast eroding
.
^.1% of 7^
the the elderly (60+) in India (excluding population
will- constitute
traditional family system in t.
the
total
male
population,
while the
x .
wake of rapid modernisation and Jammu and Kashmir where no Cen- t----sus could be undertaken because of comparable figure for 60+ females
urbanisation.’
disturbed conditions) was 57 million is 8.2%. By the year 2025, the male
compared to 20 million in 1951 (when and female proportions will be 11.9%
^Jliven the size and striking diver- the first Census after Independence and 13.4% respectively, and by the
year 2050, the comparable figures
sitv of India, it will be hazardous to was conducted).
* According to the official pro- will be 20.2% formales and 22.4% for
generalise on the impact of urbanisa­
tion and ‘modernisation’ on the eld- jections of the Registrar General, females. This is because of the higher
200 1 the elderly population
life expectancy of females compared
A
erly. In a recent survey of the elderly India, in
that of males.
to
in a middle class locality of New Delhi is estimated at 71 million, and 114 mil­
* According to UN estimates,
(1997), we found that rapid urbanisa­ lion by the year 2016 (the year for
during
the period 1995-2000 in Inc
tion and the consequent increase in which the ultimate projections were
the life expectancy of males stood at
housing shortage tends to perpetuate made).
* The United Nations projec- 62.3 years while that of females was
the joint family system.
tions (medium variant) put the esti- 62.9 years. Fortheperiod2020-25,the
This is because most young mar­
mated number of elderly in India in figures are 68.8 years for males and
ried sons do not have the capacity to
2000 at 77 million. The projection for 72.1 years for females. Forthe period
move out and pay exorbitant house
of the year 2025 is 168 million and for 2045-50 the estimates are 73 years for
rents. The result is a perpetuation
j x
males and 76.9 years for females. It
two and three-generation families 4. For detailed statistical data, see Ashish mayaiso be noted that over the decades,
staying together, creating perpetual Boseand Mala Kapurshankardass. Growing
the_gap
. between male and . female life
tension between the generations, often Old in India: Voices Reveal, Statistics Speak.
T.In
B.R. Publishing Corporation. 2000 (in press), expectancy is estimated to increase
leading to serious mother-in-law and See also Census of India,\99\,Ageing Popu- thfs situation at least, the gender gap
daughter-in-law conflicts.
lation ofIndia. Registrar General, India. 1991: affects the males ad versely.
In order to understand the social, Census of India. 1991, Population Projections
* The ageing of population conpsychological, economic and other for India and States, 1996-2016. Registrar
General, India. 1996; National Sample Survey, sequent on the change in the age struc36 3. S. Irudaya Rajan. U.S. Mishra. P. Sankara The Aged in India: A Socio-Economic Profile,
from the fact that
Sarma.India'sElderly:BurdenorChallenge? 52nd Round, 1995-96 Department Stausj
f
decades, the
Sage Publications. New Delhi, 1999. p. 20.
tics. Government of India, Calcutta, 1998.
all tnr0Uon
Ageing

growth rate of the 60+ population has
been consistently higher than that of
the total population. During 1951-61,
the decadal growth rate of the 60+
population in India was 26% compared to the growth rate of 21.6% for
the total population. During the decade 1981-91, the comparable figures
were 31.3% and 23.9%. The same
story is repeated when we consider the
male and female population separately.
Looking at regional variations
we find that in 1991, three states in
India, namely Uttar Pradesh, Maha­
rashtra and Bihar had more than 5
million persons in the 60+ category.
It may be noted that in most of the
states the population of 60+ males
exceeded that of60+females, notably
in Bihar. Madhya Pradesh, Rajasthan
and Uttar Pradesh. But in Kerala,
Maharashtra, Andhra Pradesh, Karnataka and Gujarat, the 60+ female
population exceeded the 60+ male
population.
Kerala had the highest proportion (8.8%) of 60+ population
in 1991, followed by Himachal Pradesh (8.1 %),Punjab(7.8%),Haryana
(7.7%) and Tamil Nadu (7.5%).
Among major states, the lowest pro­
portion was in Assam (5.3%) followed
by West Bengal (6.1%), Bihar (6.3%),
Rajasthan (6.3%), Gujarat (6.4%).
Madhya Pradesh (6.6%), Andhra
Pradesh (6.8%) and Uttar Pradesh
(6.9%).

A
jFVccording to the 1991 Census,
there were 22.2 million elderly (60+)
workers in India: 17.8 million males
and 4.4 million females. This implies
that 39.1% ofthe total 60+ population
were workers. The male workforce
participation rate was 60.5% while it
was 16.1 % forfemales.
There were more than a million
elderly workers in each of the follow­
ing states: U.P. (4.3 million), Bihar

(2.3), Maharashtra (2.2), M.P. (2.0),
Andhra Pradesh (1.9), Tamil Nadu
(1.7), West Bengal (1.3), Karnataka
(1.2) and Rajasthan (1.0). The elderly
workforce participation rates for these
nine states are as follows: U.P. (45%),
Bihar (42.4), Maharashtra (39), M.P.
(46.1), Andhra Pradesh (43.4), Tamil
Nadu (39.9), West Bengal (30.8), Karnataka (37.3) and Rajasthan (36.4).
Andhra Pradesh has the highest
female workforce participation rate
(24.2%) among the elderly and West
Bengal, the lowest (6.5%).
HP
I he distribution of the elderly workforce'in nine industrial categories
adopted by the Census is as follows:
(z) Cultivators 55.9%, (z’z) agricultural
labourers 22.4, (z7z) livestock, forestry
etc. 1.6, (zv) mining and quarrying 0.2,
(va) manufacturing etc. in household
industry 2.4, (v£?) manufacturing etc.
in other than household industry 3.9,
(vz) construction 1.0, (vz7) trade and
commerce 6.6, (vm) transport etc. 0.9,
(zY)otherservices5.Itwillbeseenthat
over 78% of the elderly work force is
engaged in agricultural activities. In
the case offemale workers, the figure
isover84%.
In the absence of any social
security in the agricultural sector, the
elderly fare badly and this is more true
of the female workers. Even in the
non-agricuRural sectors, there is some
social security only in the small organised sector. The problem is most acute
in the informal orunorganised sector,
The National Sample Survey
(52nd Round, 1995-96) collected data
on the economic dependence of the
elderly. The all India picture is as follows: Among the elderly rural males,
48.5% claimed that they were not
dependent on others, 18% were partially dependent and 31.3% were fully
dependent on others. In the case of
elderly rural females, 70.6% were
fully dependent on others, 14.6% were

partially dependent and only 12.1 %
said that they were not dependent on
others.
The urban scene was as follows:

51.5% of the elderly males claimed
that they were not dependent on others, 29.7% were fully dependent and
16.9% were partially dependent. In
the case ofurban females, 75.7% were
fully dependent on others, 11 % were
partially dependent and 11.5% were
not dependent on others. In West Ben­
gal, over 88% of the rural females and
85% of the urban females were fully
dependent on others. These figures are
the highest among all states.
In Kerala, which has the highest
proportion of elderly in India and
has several social security schemes,
73.6% of the rural females and 76%
of the urban females are fully dependent on others. This shows how vul­
nerable elderly women are even in
Kerala, known for its high order of
social investment. The economic
dependency ratio among females
is the lowest in the rural areas of
Himachal Pradesh where 48.7% of
the females are fully dependent on
others. Himachal has the highest
ratio of economic independence
(23.6%) among females in rural areas,
A remarkable aspect about Himachali women is little appreciated:
Because of the massive migration of
men from the rural areas to the cities
all over India, the women are left to
fend for themselves, look after the
children and the elderly as well as cattie and whatever land they possess,
The NSS statistics, reveal that
even the elderly females in the rural
areas of Himachal Pradesh have to
fend forthemselves and not depend on
others. The rural Himachali women
have no alternative but to ‘empower’
themselves.
The NSS data provides details
about the category of persons who
SEMINAR 488 - April 2000

37

J

about the role of family support in divorced or separated. In the case of
the future, 93% said that the family 60+ females, 1.4% never married ,
support system will decline and the 44.2% married, 54% were widows
elderly persons must learn to be self- and 0.4% divorced or separated,
males and 76.5% of the urban males reliant.
Over 81 % of the elderly conA
and grandchildren support 4.8% of
fessed to facing increasing stress ZA^mong the major states, West
the rural males and 5.2% of the urban
males. In the case of elderly females, and psychological problems in mod- Bengal had the highest proportion
children support 69.9% of the rural em society, while77.6% said that the of widows (65.1%) followed by
females and 67.9% of the urban mother-in-law daughter-in-law con- Karnataka (63.2%), Andhra Pradesh
females. The share of grandchildren flict was on the increase. When probe (63.1%), Tamil Nadu (60.3%) and
questions were asked, 62.9% of the Orissa(60.2%). Overall, Pondicherry
is 5.2% and 5.5% respectively.
elderly felt that the role of grandchil- had the highest proportion of widows
dren will decrease in future while (67.7%). On the other hand, states
In brief, over 75% of the economi­
82.8% said that the role of television with a low proportion of widows are
cally dependent elderly are supported will increase in future. Over 87% of Nagaland (24.5), Sikkim (32.1),
(36.5), Mizoram (38.7) an"1
by their children and grandchildren. the elderly stated that the government Haryana
. . (39.5). These^
- - au
This does indicate the almost total' was not doing enough to take care of Punjab
” ’ in
reliance on the family in the case of the the elderly
i India and about 38% affected by a range of demographic,
supported the right to die (euthanasia) economic, health and socio-cultural
elderly who are not economically
factors.
independent. The figures for Kerala, movement.
It
must
be
noted
again
that
our
If we break down the 60+ age
are telling: 83.2% of the rural elderly
sample was confined to a middle class group into 3 sub-groups we find that
males who are economically depend­
urban locality. Things would be much the percentage of widows is46.3 in the
ent are supported by the children. In
60-69 years, followed by 66.1 in the
the case of urban elderly males, the worse in poor localities as also in
70-79 age group and 69.8 in the age
figure is almost the same: 83.7%. In rural areas. Nevertheless, we do get an
the case of females, the comparable idea of the perception of the elderly group 80+. The highest proportion
of 80+ widows was in Himachal Pra­
figure is 72% both in rural and urban which is not likely to differ substan­
areas. The solidarity of the family sus­ tially in rural and urban areas. As we desh (80.9%).
The total number of 60+ widows
tains the elderly. But is this solidarity have observed earlier, the extent of
in
India
in 1991 was 14.8 million
cracking up? Neither the Census nor dependence on children is more or
while
the
number of widowers was
the NSS can provide any data on the less the same in rural and urban areas.
4.5 million. Let us look at the abso­
perception oftheelderly. Forthis, one In short, it would be unrealistic to
lute number of 60+ widows in some
assume
that
in
the
years
to
come
the
has to look to indepth case studies
government will step in to really take of the major states of Indja: Ur
and surveys of the elderly.
Pradesh (1.8 million), MaharashuWe shall present some high- care of the elderly. Hope still lies in
(1.6), Andhra Pradesh (1.4), West
lights of a survey which we conducted the solidarity of the family,
Bengal (1.3), Tamil Nadu (1.2),
in a middle class locality in New Delhi
Madhya Pradesh (1.2), Bihar (1.1)
(1997).5 While one cannot generalise ^Undoubtedly, elderly widows are
Karnataka (1.0).
from such a small study, it does give a
Our district-wise analysis shows
slimpse of what is in store for the among the most vulnerable sections
a
high
incidence of widows among the
’ ’ ofI’L.dl-L
~
----- z con­
elderly in India. Our survey revealed
India’s population.
We ‘have
ducted
a
detailed
analysis
of
marital
elderly
females in West BengaL Jn
that 97.4% of the elderly think the
Bankura
district, 72.4% of the 60+
joint family system is breaking down status in each state of India covering
women
are
widows. In Mayurbhanj
and 93.1 % think the generation gap every individual district (based on
is widening
widening in
in 1India and respect for unpublished 1991 Census data obta- district of Orissa, 66.7% of the elderly
is
the elderly is dying out. When asked inedfromtheRegistrarGeneralj.Some women are widows. In contrast, in
Tuensang district of Nagaland, only
highlights are presented below:
Of
thetoLbO?
males
in
India,
3.5%
19.7% ofthe elderly women are wid38 5. Ashish Bose, The Condition ofthe Elderly
in India: A Study in Methodology and High­ are ‘never married’, 80.7% married, ows. Without in-depth surveys and
lights ofa Pilot Survey in Delhi, \991 (UNFPA
15.5% were widowers and 0.3% studies, it is difficult to comment on
support the economically dependent
’• • ) _
elderly
■ children, grandchildren,
spouseandothers.
Inlndiaasawhole,
S
V,..—. «• -_____________________
_______ »
children support 73.2% of the rural

11

Project Report. M i meo. to be published).
Ageing

..

this strikingdiversity in the incidence
of widowhood.This should merithigh
priority in social science research,
Our sociologists and experts in gender issues must apply their minds to
this problem.

between these two groups. In Group
I, the old take over the young by the
year 2000 when 18.9% are 60+ and
18.8% are below 25. In Group II countries, the old are 8% and the young
32.3% in 2000 but by the year 2075,
the old will be 24.2% and the young
19.1%.
So in our countries the focus
must be on the young, though the elderly merit increasing attention from
planners and policy makers. Nevertheless, in the world as a whole, there
is need for a change in vision. Caring
for the old is not merely looking into
their special needs of health care,
housing and financial insecurity but a
whole lot of complex issues have to
be addressed. The empty nest syndrome reflected in small families,
the conflict of generations, a loss of
respectforthe aged, the flaws of heart­
less institutional care’of the elderly in
old people’s homes are only some of
the issues which defy easy solution,
Can spirituality come to the rescue of
the old? Can modem science prolong
healthy life to 120 years?

TP
Io get an idea of our greying world
in the decades to come, let us look at
the proportion of children (below 15
years) and elderly persons (60+) in the
world as a whole. According to United
Nations6 estimates and projections
up to 2150, in 1995, children accountedfor31.3% of the world’s population while the elderly claimed 9.5%
of the world’s population. These proportions will almost equal up by 2050
when the children’s share will be
20.5% and that of the elderly 20.7%.
By the year 2100, the elderly will
shoot ahead and claim ZlflVo of the
population, compared to 18.3% for
children. And by the year 2150, the
proportion of children will dwindle
to 17.5% while that of the elderly will
be an all time high at 30.5%. In short,
in the decades to come, there will be
more elderly persons than children In one of his humorous poems.
in our world.
A greying of the population is a Rabindranath Tagore (1893)7 suglong term and inevitable consequence gested that the young and not the old
of the sharp reduction in fertility lev­ should retire to the forest for they
els. Since this reduction .first took can appreciate what the forest offers:
place in the developed countries, ‘Like profuse blossoms, cooing of the
these are precisely the countries which cuckoo, moonlight peering through
are the front-runners of the greying flowery boughs; young couples have
revolution. The United Nations in­ no privacy at home, people come and
cludes Europe, Northern America go, bores show no sign of leaving,
and Oceania in Group I countries neighbours peep and eavesdrop - let
while Africa, Latin Ame-rica, China, the old stay at home, manage property,
India and other Asian countries (ex- fight lawsuits, keep track of money,
eluding Japan) are included in Group and let young couples move to the
II countries. The contrasts are striking forest so that they can have all the time
to themsel ves. *
6. United Nations, Population Division, World
Population Prospects: 1998 Revision, New
York, 1999. Vol I: Comprehensive Tables;
Vol 11: Sex and Age; United Nations, World
Population Projections to 2150, New York,
1998.

39

7. Rabindranath Tagore ‘Shastra’ in Kshanika,
1893. Quoted by Asim Kumar Datta in Under­
standing Greying People of India (edited by
ArunP. Bali), New Delhi, 1999.

SEMINAR 488 - April 2000

T~’"'

*

i

/•J.;

Health issues
P.C. JOSHI and S. N. SENGUPTA

mature democracy resulting in an
expanding social commitment of the
state. Beginning with the scheduled
castes and tribes, the state has gradually accepted its legitimate responsibility to care for the disabled, destitute,
mentally deranged and the elderly,
This expansion has kept pace with the
evolving image of these sections in
broader society itself.
j
The second factor relates to the
demographic transition in the country.
From 12 million in 1901 the numbe;
of the old rose to 57 millions in 1990
and is expected to cross the 100
million mark in 2013. Not only has
the absolute number of the elderly
increased, their proportion in the
population too has risen. From a mere
social welfare department but the 5.1 % in 1901, the elderly will become
planning commission, since every 21’% of the population by the year
department of the government is now 2050, estimates a United Nations
involved with the special needs and projection.
requirements of the elderly.
The third factor is related to the
The impetus to contemporary growth of activism and advocacy
elderly concerns in India can be traced spearheaded by groups of the elderly
to three main developments. The first non-government organizations and
is the evolution of civil society and a academicians. As a consequence, a

ATa recent meeting with a seniorcitizens’ forum in Delhi, we raised the
possibility of initiating a long-term
medical study on the elderly. ‘So you
wanttotreatusas guineapigs,’ was the
first query regarding our motive. The
discussion then turned to the general
issues of the elderly - from old age
■ )
pensions and railway concessions, to
health-related advancements and
—
genetic factors in dementia. Clearly,
aware and
the group was highly
1 ~
keenly debated not just the latest
media stories but the current scenario
of the aged.
The elderly in India, especially
the urban, have long been active advo­
cates of a policy on ageing. They see
theTssue ^concerning not only the

40

Ageing

X.-wr-'Ty- -

national policy for older persons has
finally been formulated, enshrining
the state’s commitment towards its
ageing population. .
In our presentation the elderly
population will be taken to mean
people aged 65 and above. Although
this definition is somewhat arbitrary,
this criteria is used by many countries
to decide eligibility for purposes of
recruitment and rehabilitation in other
societal programmes.

Projected Total Population and Elderly Population, 1990-2020
(in million: projections are medium variant)

Total

1990
>65

>80

Total

>80

Total

2020
>65 >80

5296.3

327.6

52.9

6229.3 424.4 . 67.5

8049.9

705.7 123.9

Countries

1211.1

145.5

.31.3

1278.0 172.6

35.5

1387.2

232.8

54.4

Developing
Countries

4084.2

182.1

21.6

4590.3 251.8

32.0

6662.7

472.9

69.0

Region •

World

Developed

2000
>65

ble the number in developed countries. Three of the four countries projected to have the largest number of
■ opulation ageing in developed old people in the year 2025 are China,
countries is a reflection ofa decline in India and Indonesia.2The growth proboth mortality and fertility. In some jected for older population in devedeveloped countries, 15%ormoreof loping countries has considerable
the population is already 65 and older implications for health and social
while 3.4% are aged 80 or older.1 policies. The old population itself is
Althoush the percentage of the elderly getting older with people over 80
in the population in developing coun- years of age forming the fastest growtries is substantially lower than in ing subgroup of the population in
developed countries, the absolute many countries. Developing countries
numbers ofold people worldwide are too are likely to experience a modest
considerable. For example, in India increase in the proportion of the popuwhere only 3.4% are 65 and above, lation in the oldest age range.
In most developed countries,
they still number 30 million. In 1988,
there were an estimated 159 million there are about 65 men for every 100
persons aged 65 and older in develop- women in the age group of 65 and
ing countries compared to 140 million above. Generally in developing counin developed countries and over 60% tries, especially India, there are more
of the monthly global net increase in old men than old women. The sex
older persons was in the developing ratio will probably fall in many developing countries with female life
countries.
Between 1990 to 2025, the per­ expectancy projected to increase
centage of the population aged 65 faster than male life expectancy. In
and older is expected to increase to most developing countries, more than
just over 20% in Europe and North 50% of women aged 65 years and
America and to double from 5 to older are widowed and in some coun10% in Asia, Latin America and the tries more than 75% of the women
Caribbean.
aged 75 and older are widowed. In
The above projections indicate contrast, there is no country in which
■ ■by the
- year 2020,
--------there3 will be 470 more than 40% of men aged 75 and
that
million people aged 65 and older in olderaresingle.
Marital status has the greatest
developing countries, more than douimpact on living arrangements of the
1. K. Kinsella and C.M. Taeubar, An Aging ----------------

elderly population. In developing
countries, the proportion of persons
aged 65 and above who live alone
ranges from 10% (Japan) to 90%
(Sweden).
This xproportion is smaller
(
in developing countries where there is
a tradition of multi-generation households and both married and widowed
older persons commonly live with
theirchildren and grandchildren,
The past century saw a remark­
able improvement in life expectancy
although tremendous disparities exist
between developed and developing
countries. Life expectancy at birth in
most developed countries is 70-75
years for men and 76-81 years for
women; it is 11 years less in developing countries. In the past few decades,
there has also been a substantial reduction in mortality among older persons
resulting in an increase in lifeexpectancy at age 65.
A nationwide survey conducted
by the National Sample Survey Organization,3 reported that 45% of the elderly suffered chronic illnesses. Nearly
70% in the urban and 34% in the rural
areas were economically dependent.
The percentage of the elderly living
alone was 6 and 8% respectively for
theurban and rural areas. This proportion is, however, expected to increase
in the coming years, necessitating
appropriate measures for the rehabilitation of the elderly. These sociodemographic factors not only influ-

World H. US Government Printing Office,
Washington D.C., 1992. Also, UNDP, Human
Development Report 1990,QkIov6 University
Press, New York, 1990.

3. NSSO, ‘Socio-economic Profile of Aged
Persons’, Sarvekshana 15(1-2), 1991.

2. J.S. Siegel and S.L. Hoover, ‘Demographic
Aspects of the Health of the Elderly to the Year
2000 and Beyond’, World Health Statistical
Quarterly 35,1982, pp. 132-202.

SEMINAR 488 - April 2000

.........................................

.............................................................’................................................. "

41

• ‘
The WHO defines stroke or
Besides these common infections,
;
are
also
susceptible
to
cardiovascular
disease (CVD) as the
the elderly
gastrointestinal infections, pressure rapidly developing clinical sign of
sores, septic arthritis, septicaemia focal or global disturbance of cerebral
and meningitis. The susceptibility of functions with symptoms lasting 24
■ "
’ j hours or more or leading to death,
the dual medical problems of both the elderly to these infections
along
with
factors
such
as
poverty,
lack
of The crude prevalence rate computed
. • communicable as well as degenera- 1
tive disease. This is further com- proper nutrition and absence of com- from different community surveys is
pounded by impairments of special prehensive health care calls for special about 200/100,000 persons, type­
tension,
tobacco use,
*
" obesity and dia­
sensory functions like vision and hear­ immunization prografnmes.
betes mellitus are important risk
ing. The elderly are highly vulnerable
factors for stroke. Stroke victims
to infectious diseases because of a
lhe
chronic
illnesses
in
the
elderly
impose enormous economic burden
decline in their immune functions and
on
our meagre health care resources.
atrophic changes in various organs. usually include hypertension, coro­
Cataract is the most common
The physiological changes in the old nary heart disease and diabetes
cause
of blindness among the elderly
a^e lead to impaired coush reflex, mellitus. The pi evalence of hypertenwas found to be higher in females, in India. Nearly 1.5% are blind, a
impaired circulation and tissue per- sion
£
fusion. There is.deficient collagen - affecting as many as 323 per 1000 majority of them in the rural areas
synthesis and poor wound healing. females in the rural areas.5 Coronary Alongside physical disability blind­
Further, incidence of infection remains heart disease was found to be more ness also impinges on the mental,
high because of poor nutrition and common in urban areas, and higher social and financial status of the indi­
high intake of immunosuppressive for males than females. Given dietary viduals and their families. The WHOchanges and lifestyle factors, such dis- -------NCPB surveyi estimated that 12
drugs.
eases will show an increase in the million Indians were blind and in need
of eye care services in 1989.6
j^^mong infectious diseases, pneu­ coming years, thereby requiring spe­
cial health, nutrition and lifestyle
monia is 50 times more common in counselling. Diabetes mellitus, which
study on the health care for the
the elderly than in adolescents and it affected 5 million elderly in 1996, is
rural aged in Madurai district, Tamil
for ---half---------the deaths caused also higherin urban than rural areas.
accounts 1~.
Nadu,7 reported that of the 1910
To
check
for
malignancy,
popu
­
due to respiratory diseases, excluding
elderly screened, 88% had visual
cancer. Urinary tract infections are lation based cancer registries were
initiated to estimate the incidence of complaints, 40% had locomotion difparticularly common in the elderly.
Asymptomatic bacteriuria affects cancer under the National Cancer ficulties, followed by symptoms of •
30% o'f elderly women and 7% of Registry Programme of ICMR in central nervous system (14%), cardio­
vascular (17%), respiration (16%),
elderly men. The common cause of Mumbai, Chennai and Bangalore in
1
982
and
in
Delhi
and
Bhopal
in
1
987.
dermatological (13 %), gastrointe
urinary tract infection in the elderly
The
incidence
of
cancer
was
higher
tinal (10%), psychiatric (4%) and
is insertion of catheter and other ins­
in both elderly males and females acoustic (8%). 2% of those sampled
truments.
suffered from neoplasm.
A study
*
- of
The prevalence of TB is higher as compared to the total population. £.-----among the elderly than younger indi- In 1996, the total number of elderly the knowledge, attitude and pracviduals.Astudyof 100 elderly people persons with cancer was around 0.35 dees8 regarding nutrition among the
in Himachal Pradesh,4 found that million. Cancer prostrate is the com- —-----------most ofthe patients came from a rural monest malignancy/ in males. The
background. They were also smokers chance for contracting this disease sramme of control of Blindness, Directorate
and alcoholics. Endocarditis thus is among males over 50 years is 30% and of Health Services, Ministry of Health and
Family Welfare’New Delhi’1992’ PP-80’100a major factor in elderly mortality, mortality is 25%.
7. A. Venkoba Rao, Health Care ofRuralAged,
accounting for 50% of the cases.
Indian Council of Medical Research, New
ence the extent and severity of morbidity among the elderly but also their
quality of life.
r-”ocountryj like
In a developing
India, the elderly people suffer from

42

4. V.K. Arora and R.S. Bedi. ‘GeriatricTuberculosis in Himachal Pradesh: A Clinical Ra­
diological Profile’, Journal ofthe Association
ofPhysicians in India 31,1989, pp. 205-207.

Ageing

-**■

r* *r. ■*'

«

5. R. Kutty, S. Radhakrishna, K. Ramachandran
and N. Gopinath, ‘Prevalence of Coronary
Heart Disease in the Rural Population of Thiruvananthapuram, Kerala’, India Internatio­
nal Journal ofCardiology 39,1963, pp. 59-70.

Delhi, 1990.
8. M. Srivastava, U. Kapil, V. Kumar. A.B.
Dey, K.M. Nagarkar andG. Sekaran, ‘Know­
ledge, Attitude and Practices Regarding

i

elderly, observed that fruits, leafy
green vegetables and milk were rarely
consumed in adequate amounts in a
general belief that such expensive
foods should be given to younger
people. No wonder most of our eld­
erly population reports nutritional
problems.
According to Government of
India statistics,9 cardiovascular disorders account for one-third ofelderly
mortality. Respiratory disorders cause
10% mortality while infections and
tuberculosis account foranother 10%.
Neoplasm accounts for 6% and accidents, poisoning and violence constitute less than 4% of elderly mortality
with similar rates for nutritional,
metabolic, gastrointestinal and genito­
urinary'infections.

lElderly individuals usually face a

higher risk of developing mental as
well as physical morbidity. Their vulnerability to mental problems is due
to ageing of the brain, physical problems. socio-economic factors, cerebral pathology, emotional attitude and
family structure. The biochemical and
morphological changes in the ageing
brain of normal individuals are similar to those suffering from dementia,
In most cases, mental illnesses coexist alongside physical problems
in the elderly persons. Chronic physical disorders and sensory impairments (vision and hearing defects)
• are known to be especially associated
with mental problems of the elderly.
The incidence of mental illness
is strongly influenced by socio eco-

I

i

Nutrition in Patients Attending Geriatric Clinic
at AllMS', in V. Kumar (ed), Ageing: Indian
Perspective and Global Scenario. AIIMS,
New Delhi. 1996. pp. 407-409.
9. S. Guha Ray, ‘Morbidity Related Epide­
miological Determinants in Indian Aged An Overview’, in C.R. Ramachandran and
B. Shah (eds). Public Health Implications of
Ageing in India, Indian Council of Medical
Research. New Delhi. 1994.

nomic factors like educational levels,
degree of economic support, whether
living alone, and so on. The presence
of dissatisfaction with life and feel­
ings of loneliness and self-pity show
a high correlation with mental problems. So does the family structure and
situational factors such as a widowed
status and fall in income. All these
significantly contribute to emotional
problems in old age.

■ he magnitude of mental morbi­
dity in the Indian situation is a serious cause of concern. In India, nearly
4 million elderly persons (age 60
and above) are mentally ill, which,
although lower than in western coun­
tries, requires to be taken seriously as
the necessary psychiatric services
fall woefully short of our require­
ments. Two-third of mental morbi­
dity is affective disorders especially
depression and late onset of psychosis, while one-third is dementia.
According to one estimate, 10
the prevalence of depression ranged
between 13 and 22% among the elderly and it was most often associated
with cerebral pathology. Many of the
elderly suffer from higher mental
function disturbances like memory
problems. Another common problem
reported in a major hospital study"
was mania, accounting for 16% of
the psychiatric diagnosis. Mania
was more common in males and
often accompanied by organic brain
syndrome.
The risk factors for mental
morbidity in the ageing population
stand comparatively higher than for
the general population, estimated at 7
per lakh for the general population as
10. A. Venkoba Rao, ‘Mental Health and
Ageing in India’, Indian Journal of Psychiarzy 23,1981, pp. 11-20.
11. L. Thomas, Late Hight Thoughts ofListen­
ing to Mahler's Ninth Symphony, Bantam
Books, New York, 1984.

compared to 12 per lakh for the elderly. The main risk factors are loss of
fortune, fall in self-esteem, sense of
helplessness, poor education, substandard health, social and gender discrimination, Financial debt and status
as a widowed person.
Anxiety disorders are more
common in the elderly population,
Generalized anxiety disorders are
accompanied by depression. In the
category of late onset psychosis, the
delusions in late paraphrenia may be
persecutory, sexual and hypochondiacal. The hallucinations in the
elderly are often multi-modal and
associated with sensory impairments,

■ he psycho-physical problems
which the elderly confront due to ageing and associated socio-cultural,
nutritional and environmental factors
demand that we perceive the health of
the elderly within a holistic perspective. The maxim of adding years to
life implies that the elderly receive
adequate state and social support to
live an active and socially produc­
tive life. At the minimum we require
comprehensive health care directed to
the elderly, in particular equipping
ourPHCs in geriatric care. Equally, it
is important to learn from the experi­
ence of other countries where too the
elderly face enormous problems due
to weak social support mechanisms,
Fortunately, our cultural ethos
gives -a special place to the elderly as
wise people and counsellors of society. Both geriatric support and social
engineering aimed at improving the
competence of the elderly and ensuring their active participation in society should be considered together in
evolving any policy on ageing care.
The experience and wisdom of old
age is a treasure for any society; its
gainful utilization would be benefi­
cial for both the elderly as well as the
younger generation.
SEMINAR 488 - April 2000

'■

*

43

I

Societal responses
MALA KAPUR SHANKARDASS

INDIA has a rich tradition of philanthropic and voluntary activities for
mitigating the sufferings of disadvantaged and marginalized people. The
old, particularly the poor, frail, disabled and homeless over the centuries
have been beneficiaries of various ini­
tiatives, though not adequate, sup­
ported by voluntarism and/or state
provisions. Indeed, the voluntary sector was the first to respond to the prob-

which can become critical when trying
to match the opportunity structures
provided by different organizations to
potential workers.
In recent decades, the processef
• i change
..------ 3 — modernization,
of social
urbanization and technological change
leading to urban migration, employ­
ment of women outside the home,
nuclear families - have undermined
the traditional patterns of care of the
elderly, that is by the family. Given
lems of the elderly in India.1
Beginning with the enactment changing value systems and priorities,
of the Societies Registration Act provisions for the care of older per­
of 1860, ‘voluntary organizations’ sons have increasingly to be provided
encompassing a wide range of agen- by voluntaryorgamzations/NGOs.
A directory of voluntary agen­
cies, viz. societies, cooperatives,
cies
for
the welfare of the aged in India
trusts, and trade unions - have been
given a legitimate place in the welfare compiled in 1982 by CEWA3 listed
mechanisms in the country. They are 379 agencies; the number of new ones
now more popularly referred to as established each decade showing an
non-governmental organizations increase especially after India attained
(NGOs) in order to have some uni­ Independence. Significantly, mor
formity with regard to international than half are located in the southern
states and Maharashtra. 13 states and
terminology.
While this uniformity makes union territories did not have any
for convenience, it also creates a false registered voluntary agency working
picture of homogeneity, particularly for older persons. About 86% of the
to those persons who are not con- listed agencies are institutions providnected with voluntary action.2 There ing services like day care, recreation,
;;;
J *between orga-- counselling,
geriatric care (medical
is a subtle difference
(
nized voluntary action and non gov- and psychiatric care) and
as
ernmental organization functioning. assistance. Information in the CEWA
directory indicates that the number of
1. Manabendra Mandal,‘The Work of the NGOs per million persons aged 60
NGOs for Older Persons’, Research and Deve- pius fOrthe country as a whole is 6.46.
lopment Journal 5(V), 1998, p. 24.
2. K.K. Mukherjee and Sutapa Mukherjee, Vol­ 3. Care of the Elderly: Directory of Voluntary
untary Organizations: Some Perspectives, Agencies forthe Welfare of the Aged in India,
Gandhi Peace Centre, Hyderabad, 1988, p. 4. CEWA, Madras, 1’982.

44

Ageing

1

•1
I

A decade later in 1992,theHandbook of Information publ ished by the
Association of Senior Citizens4 listed
665 organizations in India working
in the field of welfare of the aged. The
list included old age homes, day care
centres, pensioners’ associations,
institutions providing medical help,
institutes devoted to research, and
associations of senior citizens.
Most registered voluntary agencies provide institutional care in the
form of old age homes, either as free
facilities or on a ‘pay and stay’ basis.
Many of these are set up under religious auspices. Old age homes in
India are used by the ‘needy’ elderly
to pass their last days either as a last
resort when for various reasons the
family support system breaks down,
orfor seeking solace while disengag­
ing from family and social concerns.
The quality of care in these homes varies, ranging from the bare minimum
of lodging and boarding facilities to
provisions for medical services,
though at only primary level, recrea­
tional pursuits, and social activity.5

comprehensive analysis of old
age homes in the country is not avail­
able though the first old age home in
India was set up as far back as the early
18th century.Ageneralunderstanding
ofthe institutional care facilities available to older persons in the country is
provided in a monograph titled, ‘Care
for Elderly' .6The monograph lists 329
institutions involved in care of the eld­
erly, out of which only 4 were under
the auspices of the government. 189
of the elderly care centres listed were
run by Christians, 12 by Hindus, 2 by
4. Handbook of Information. Association of
SeniorCitizens. Bombay. 1992.
5. Maia Kapur Shankardass, ‘Towards the
Welfare ofthe Elderly in India', Bold: Quarterly
Journal ofthe International Institute on Ageing,
5(1). United Nations, Malta. August 1995.
6. Care for Elderly, a monograph. Madras
Institute ofAgeing, 1989.

Muslims, and 117 were under secular
Muslims,and
auspices, with 5 put underthe category
of ‘others’. Of the listed institutions
88% functioned as old age homes while
6% were engaged in providing health
care and self-employment opportunities. 6% of voluntary organizations
also provided day care facilities.

JI of 1989, based on information
j^kis
jT^s of 1989, based on information
in the monograph, 15,471 elderly were
accommodated in old age homes
available in the country. A Directory
ofOld Age Homes in India7 published
in 1995 referred to 354 institutions,
Based on a nationwide survey and
responses from 256 old age homes,
the Directory indicated that 12,702
elderly persons resided in these establishments, not all of which were registered with the government. Another
survey carried out on old age homes
in the country by the Centre for Deve­
lopment Studies, Trivandrum8 to
which only 186 homes responded
ijidicated that most of the funds for
these institutions came through reli­
gious organizations, private sources
and other types of trusts and caste
organizations.
The role of voluntary agencies/
NGOs in the care of older persons has
become important because central
and state government activities and
funding for the welfare of the elderly
are limited. In fact, the government
solicits active participation ofthe vol­
untary sector to meet the needs of
older persons. The role of the voluntary sector in ensuring welfare to various segments of the population,
including the elderly, has been emphasized in the Sth and 9th plan documents. The National Policy on Older
7. Directory of Old Age Homes in India.

Research and Development Division, HelpAge India, 1995.
8. For further details refer to S. IrudayaRajan.
U.S.Mishra andP. Sankara Sama. India sEld­
erly: Burden or Challenge ? Sage Publications.
New Delhi 1999.

Persons announced in January 1999
by the government talks of promoting
andassisting voluntary organizations
for providing non-institutional services, construction and maintenance of
old age homes, organizing services
such as day care, multi-servicecitizen’s
centres, reach out services, supply of
disability related aids and appliances,
short term stay services and friendly
home visits by social workers.
It was in 1983-84 that the govemment for the first time decided to
make grants to voluntary organizations for services to the aged. The
grants-in-aid-provision is for (z) rendering welfare services to the aged,
such as health care, income generation, subsistence training; and (zz) for
constructing homes for the aged,
Overthe years many NGOs have been
supported from the budget outlays
of the respective state governments.
But, with most state governments
giving low priority to the welfare of
the elderly, and the low social encouragement given to the concept of‘voluntary ’ care vis-a-vis family care, the
provision for grants has not been
optimally used by the voluntary sector,

Inuring the Sth five yearplan, wel­
fare measures for the elderly were
made more specific and comprehen­
sive. Consequently in November
1992, the Ministry ofWelfare initiated
a scheme called ‘Welfare of the Aged’
toencourage voluntary organizations
through grant-in-aid assistance to
provide old age homes, day care centres, mobile medicare and non institutional services for older persons above
the age of 60. The scheme marks the
entry of the ageing population as a
target group in national planning and
recognises the voluntary sector as
constituting an important institutio­
nal mechanism in providing services
complementing the endeavours of
the state.
SEMINAR 488 - April 2000

1

45

By 1995,212oldage homes, 31
mobile medicare units, and a number
of day care centres set up by the vol­
untary sector received assistance from
government funds marked forthe pur­
pose. However, since the scheme did
not specify the services to be provided.
no proper momtonng/evaluation was
carried out. Consequently we have no
worthwhile assessment of the functioning of the scheme.
Though the government has
voiced official support for a larger role
for NGOs and a number of voluntary
organizations are active in the field of
ageing in different cities and regions,
at the national level the inputs remain
limited. Moreover, vast differences
exist among NGO approaches, roles
and capabilities. Some are part of the
government service delivery system,
some are small independent service
organizations, and others are trying
out new approaches.

46

conferences to focus on the problems

of pensioners and other elderly citizens. The Samaj helps the needy pensioners through a benevolent fund
created through contributions from
its well-to-do pensioner members,
All pensioners are eligible to become
members of the organization as per
i
the procedure laid down by the Samaj.
CARITAS India, a member of
CARITAS International undertakes
activities in different states and union
territories of India. It is the official
national level organization of the
Catholic Bishops Conference of India,
established for the education and
animation of society at all levels. It
aims to promote care for the sick,
crippled, handicapped, destitute and
the aged,
The Indian Association of Retired

(
” persons to -lead- a healthy and digolder
nified post-retirement life,
The membership to this voluntary body is open to all physically fit
persons 21 years of age and above,
irrespective of caste, creed or sex.
With current membership of 1500
volunteers it enjoys patronage from
the government, receiving grants for
a number of its programmes and
projects. It has also been recognized
by the United Nations and is listed in
the UN Handbook of Organizations
active in the field of Ageing (1988
edition).
Age-Care India started off in
1981 organising free geriatric health
check-up camps in Delhi forthe urban
poor and soon spread its network to
provide the much needed health care
services to the rural poor and elderly
from low income groups around the
metropolis. The camps, essentially a
preventive measure, had till mid1999 covered about 56,000 aged
people above 50 years of age. The
organization has over time opened
branches at Jaipur for Rajasthan,
Shimla for Himachal Pradesh, Dehra
Dun for Uttar Pradesh, Faridabad for
Haryana, Calcutta for West Bengal
and Bhopal for activities in Madhya
Pradesh.

Persons is funded through member­
ship fees, donations and grants-inaid from the government and underfew NGOs have managed to takesa variety of programmes for the
establish a positive track record and welfare of retired persons. The asso­
gained support for their development ciation organizes regular talks and
work from international and national discussions with the authorities to
donors. Reference can be made here project the problems faced by retired
to five voluntary organizations func­ persons in society. Headquartered
tioning at the national level: Bharat in Bombay, this voluntary body has
Pensioners’ Samaj established in opened its membership to all retired
1960, CARITAS India (1962), Indian persons and those above the age of 60 Ihrough voluntary donations from
Association of Retired Persons (1973), years. It brings out a quarterly bulleHelpAgeIndia(1978),andAge-Care tin and in recent years has started a philanthropists and affluent persons
India(1980).
project for providing socio-medical in society, the organization has started
Bharat Pensioners’ Samaj is an and financial help to its members. It a pension scheme providing Rs 100
all-India federation of pensioners has also established a well-equipped per month to the economically weak
associations headquartered at New library in Bombay.
and indigent elderly, particularly from
Delhi. It functions as a nodal point
Age-Care was established as rural areas. The scheme is intended to
for pensioners belonging to central a non-political, non-profit, secular, make a difference to the needy aged
and state governments and quasi- charitable, educational, cultural, and people above the age of 65 years.
govemmental organizations. It high- social welfare society for the care of Similarly, a disability relief fund has
lights the difficulties faced by aged the aged people. Initiated by its been created at the Age-Care head
pensioners and other senior citizens founder secretary, N.L. Kumar, who office forrendering immediate finanat various forums and strives to solve managed the support of a group of cial assistance (upto a maximum limit
the grievances of its members by dedicated founder members from ofRs 500) to the needy elderly during ''
negotiating with appropriate authori­ various walks of life and with diverse emergencies, accidents and sudden
ties. It holds periodic seminars and life experiences, itfocuses on helping physical disability.
Ageing

In addition, the organization has gramme which enables older people especially NRIs, can sponsor their
set up day care centres, holds regular to assume an active role in looking parents to the club, which is chiefly
weekly public lectures on topics
t ’ of aftertheirown health while encourag­
concerned with the problems of the
ageing and allied interests, also semi­ ing others to do the same. 95 MMUs are
privileged elderly otherwise lacking
nars and conferences, creates aware­ at present servicing lakhs of older organized help.
ness about problems of older persons persons residing in slums, resettleThe services arranged for the
among school and college students, ment colonies and adjoining rural
elderly range from legal assistance,
and organises yoga and nature cure areas, providing medicines, counselfinancial advice, ambulance service,
trainingfortheelderly. An innovative ing and health care free ofcost. In 1998help with pension problems, property
new project, day centre on wheels, £999 alone, HelpAge India spent over tax notice, wealth/income tax assess­
which provides services like medical Rs 1 crore on the MMU project.
ment orders, and so on. The Foundation
consultations, BP check-up, spot
levies a fixed tariff on the subscriber,
counselling, and collates information
to be billed every month depending
pertaining to available facilities and ^Jesides these national level volun­
on the frequency of use. It runs an
services for seniors. The organization tary organizations, a number of regio- employment exchange forolderperbrings out a monthly publication, nal and local level NGOs have set up sons, help line, involves elders as
Age-Care News, for the general reader multi-service facilities and innovative volunteers for social work and pro­
and celebrates Elders’ Day on 18 Nov­ programmes. Mention can be made vides a platform to interact with other
ember every year to honour senior here of the Action for Social Help fellow senior citizens. The Agewell
citizens above 80 years as part of its Assistance (ASHA), Family Welfare Foundation while charging costs of
annual day function.
Agency, Dignity Foundation, Deve- professional services, acts as a bridge

R

lopment, Welfare and Research Foun­

in helping members access the Tight’
u
dation (DWARF), Meals on Wheels, sources to alleviate their specific
1 lelpAge India is the country’s

and so on, all operating in different problems.
largest voluntary organization with 23 parts of the country. Their activity
regional offices. Receiving nominal relates to providing second1 careers,
careers. ^^espite the NGO/voluntary sector
grants from the central government, income generating activities, comthe organization runs on charity funds panionship, nutritional counselling,
coming forward to meet the growing
collected through motivating students cooked meals, help-line services and
needs of older persons, further steps
and youth organizations, from private promoting active ageing. As a result, need to be taken to create mechanand public sectors, and through sell- in recent years age care services have isms for the proper and adequate deliing flags and greeting cards. Its pri- become increasingly available in
_
------------ — very of services. There is an urgent
mary focus is to provide financial1 non-urbanareas.
needtoexpandprovisions.strengthen
non-urban areas.
support to other voluntary agencies
A
new
strata
of
old
people
capacities,
geographical disdis­
A new strata of old people capacities, balance
balance geographical
engaged in the welfare of the aged, requiring multifarious affordable tribution.criticallyevaluatethefuncLmres
ltSreSe
^ChanddeVe
°Pment faciIities
Parents of non resi- tioning of different programmes,
—h its
research
and development
facilities are the parents
., it trains personnel engaged dent Indians (NRIs) or inland profes- involve the community in taking care
in the care of the aged. It
n is accredited
77±t:d sionals/businessmen who though of the aged, and sensitize and"consto the United Nations and is <closely
*
financially well-off are unable to per- cientize the populace to the issues of
associated with Help the Aged,
_ ". UK.■ sonally attend to their parents. A large ageing.
It is also a founder member of Help- number of elderly now livealone withEqually, there is need to set up
Age International.
out their children, and require care. an apex/nodal agency to coordinate
Over the years, HelpAge India assistance, help and services at their and synergize the different activities
has supported 1,600 projects at a cost place of residence.
and programmes, as also network
of Rs 130crore.9In 1998-1999 alone,-»
‘
y
___
The Agewell
Foundation,
for- the various actors. Given the increas­
it supported 190projects to the tune of mally launched on 6 April 1999 at ing costs of service provision, we need
over Rs 13 crore. One of the important Delhi with support from the Ministry to encourage resource sharing and
initiatives taken by the organization is of Social Justice and Empowerment promote voluntarism if we are to adethe mobile medicare unit (MMU) pro- operates like a club by offering a life quately respond to the diverse and 47
membership of Rs 5000 to an indi- multiple needs of our growing aged
9. HelpAge India, Annual Report 1998-1999. vidual or an elderly couple. Chi Idren, population.
r.._

.

‘

_

SEMINAR 488 - April 2000

I

Interview
M.M. Sabharwal is best knownfor his extraordinary
work in the care ofthe aged. After a distinguished cor­
porate career, he joined HelpAge India, a voluntary
charity organization set up by Help the Aged of U.K.
in 1980. In his two decade long involvement with these
organizations, he has served as Chairman of both
HelpAge India andHelpAge International. Currently
he is President Emeritus ofHelpAge India and contin­
ues his active association with the movement of the
aged. He was interviewed by Mala K. Shankardass.
•-

48

•

A

You joined HelpAge India, a charity organization at
a time when you were a successful corporate sector
executive. How didyou make the movefrom a business
orientation to voluntarism ?
It was not difficult as my heart identified with the
cause - to foster welfare especially of the needy aged.
Ageing

..............................................■”

...... ....

My only hesitation was whether I would be able to
devote enough time to a cause which requires dedica­
tion and commitment. What prompted me to be part
of the team to raise funds for programmes to assist the
elderly was a belief in the need to raise awareness
about the problems of the elderly in the country and
start projects which would assist them irrespective of
caste orcreed. I do not believe in charity, ‘giving fish
to eat’; I am forteaching people how to fish. I look upon
my involvement with ageing issues as a challenge,
setting a new agenda for the welfare of the elderly,
particularly those unfortunate poor, disadvantaged
and isolated aged, who need help and assistance for
integration in society.
It seems that your personal mission merged with'
that of the organization. How did you plan and work

<

to wards the goal ofimproving the quality oflife ofolder
persons?
No programmes can be initiated and objectives
achieved without funds. Resource mobilization raising adequate funds for the ever-increasing number
of age care programmes each year is of paramount
importance. My connections with the corporate
world were of some value and helped in building
the image of the organization. We started with the
school education-cum-fund-raising programme as
our major fund-raising effort. Overtime, it has become
the mainstay of our resource mobilization activity
which includes use of video films, audio-visuals,
advertisements, sponsored events, and so on.
The involvement of school children in the cause
can be judged from the fact that in 1998-1999 just one
school - Holy Angels in Chennai - collected as much
as Rs 5.04 lakh. Reaching out to people who believe
in ‘live to give’ through students, direct mail appeal,
sale of greeting cards, and through approaching cor­
porate houses for donations and sponsorships, we
were able to raise Rs 15.90crore last year.
The funds finance a variety of age-care pro­
grammes focusing on enhancing the well-being of
elders in society. We work towards ensuring and pro­
moting dignity, empowerment and value of older per­
sons. Over the years we have supported 1,600 projects
at the cost of Rs 130 crore, this is of course calculating
the costs at current price. We try to be conscious of
present day circumstances.

What do you think is our most urgent problem? Has
ageing emerged as an issue ?
People living to older ages is an achievement. But
when people 1 i ve longer and enjoy no social security have to live below the poverty line, as widows, lonely
and ignored by families, community or society - then
ageing becomes a problem. In India, we must realize
that ageing of the population is taking place at a rapid
pace. Today we have about 77 million elderly in the
population, by 2025 they will be a whopping 177 mil­
lion. The problem arises because 90% of older persons
are from the unorganized sector which has no social
security system for the old; about 80% live in rural
areas with inadequate medical facilities; almost
40% are below the poverty line; 60% of 60 plus women
are widows, the most disadvantaged in society; 73%
of 60 plus are illiterates-the situation is grim for older
persons in our society.
I believe that ageing is one of the most crucial
issues vying for attention. If there is no intervention

now, the situation will lead to an increase in the num­
bers of destitute elderly, decrease in per capita income
and the quality of life of older persons. The basic prob­
lem of older persons in our society is a lack of security
at three levels: financial, medical and emotional. We
must have programmes to address these issues and
plans to overcome these problems.
You have been involved with ageing issues now for
twenty years, what concrete steps have been taken to
tackle the problem ?
HelpAge India’s work encompasses a broad
spectrum - from providing care to older persons, communication and advocacy, development of grassroot
organizations and assisting the formation of national
strategies, policies and legislation on ageing. We have
designed and implemented programmes focusing on
improved access to health and eye care services, com­
munity based services, income generating activities
and training. Over the years the organization has con­
ducted lakhs of cataract operations free. We have
started and supported numerous income generating
programmes which have helped the elderly to be gain­
fully occupied, improve the families’ economic con­
dition, provide relief from indebtedness, enable elderly
to become owners of looms, raise the status of older
persons, and so on. Our guiding principle is ‘Earn a
living, learn a craft.’
Our day care centres provide the elderly oppor­
tunities for companionship, recreation, healthcare
and nutrition. We have also recently started income
generation activities through these centres. For ins­
tance the centre at Yamuna Nagar, Haryana runs a
durrie making project for older women. This project
provides them with equipment and material. HelpAge
India is supporting almost half the old age homes in
the country and these now spell security, care and love
for old people.
HelpAge India’s Adopt-a-Gran (AAG) pro­
gramme is widely acclaimed for its concept. It links
older people in need with sponsoring families, indi­
viduals and corporates. Under this scheme help is
provided in the form of food, clothing, medical care,
bedding, articles of personal use and pocket money.
Last year Rs 8.11 crore was spent on the AAG pro­
gramme. Besides this, we have started an other remark­
able programme. HelpAge India has evolved the
scheme of micro-credit under which some form of
credit or revolving loan is provided to project partici­
pants to start income generating activities. Another
innovative project is the production of vermi compost
SEMINAR 488 - April 2000

49

*.

through eco-friendly methods in Rajasthan, which is
benefiting more than 100 older persons in the lower
income group through each installation.

It seems that HelpAge India’s main activities arefund
raising and service projectsfor the elderly. Should not
research be important to understand the situation ?
At HelpAge India we are interested in studying
the problems related to age-care and in evolving more
effective techniques of training, research and develop­
ment of facilities in order to optimize the returns and
benefits of the funds spent on our programmes. On
4 October 1990, the President of India inaugurated
our training, research and development centre in
New Delhi. The centre is engaged in both training of
personnel engaged in age-care work, and research
and development connected with age-care.
We organize training workshops, seminars and
visits to well run age-care institutions. These pro­
grammes are aimed at increasing the knowledge and
skills of all levels of personnel engaged in voluntary
organizations working forage-care. Ourdevelopment
activities focus on creating service facilities for
elderly citizens in public institutions as well as in ins­
titutions in the government sector.

How is HelpAge India s liaison with the government?
We work in active association with government
departments to further the cause of the elderly. In 1984
we served as the only voluntary organization represent­
ing the elderly on the working group appointed by the
Planning Commission to prepare recommendations for
the seventh five year plan. We are increasingly associ­
ated with various committees and groups constituted
by the Government of India for the welfare of the
elderly persons. We have also received active support
from the directorates of education, social welfare and
cultural affairs of various state governments and the
Union Ministry of Welfare in the implementation of
some of our programmes.

50

The organization runs projects in different parts ofthe
country, what is its organizational structure ?
We have distinguished national personalities like
The President of Indiaand the former President among
our patrons. This imposes a great responsibility on us
-while it enhances our image, we have to maintain and
improve ourcredibility. The governing body comprises
of eminent persons from different walks of life who
oversee the affairs of the set up. The director general
looks after the overall planning and implementation of
Ageing

W--

our policies and programmes with the support of func­
tional directorates at the head office. The organization
has 24 regional and area offices located throughout the
country. Though the functioning of HelpAge remains
centralized, since it has expanded its operations to all
parts of the country the time has come to initiate a pro­
cess of decentralization. We plan to have members on
the governing body representing the 4 metros of the
country and provide greater autonomy to the regions.

Besides motivating people to donate for ageing con­
cerns, has HelpAge been able to change people’s ideas
about ageing and related issues ?
The wide acceptance of our Legacy Campaign
indicates that people are now willing to think differ­
ently. In 1995-96 we launched a campaign to persuade
people to think about HelpAge India in their wills.
An increasing number of donors have shown their
commitment to the cause of the aged by making
HelpAge India a beneficiary in their will. Ihave willed
my house to the organization and a number of my
friends have also followed suit. There is this new phe­
nomenon-promoting cause related marketing-which
means that you buy a product and a small percentage
goes to a cause. The Standard Chartered Bank has
started-a credit card scheme which is linked to HelpAge
India; the Godrej companies have also come forward
to support us in this endeavour.
What is the future of HelpAge India and of the volun­
tary sector in ageing issues ?
HelpAge India has established itself nationally
and internationally. We enjoy accreditation with the •
United Nations, are closely associated with Help the
Aged, UK, and are a founder-member of HelpAge
International which has a network in 50 countries.
My association with both these organizations has
helped the cause of the elderly to cross national bounda­
ries. Since our annual income is growing, reaching
Rs 20 crore this year, we are able to undertake new
projects and expand as well as strengthen the old ones.
We are currently helping evolve a plan of action for
implementing the national policy on older persons
announced by the government in January 1999.
The voluntary sector has a crucial role to play in
raising awareness about ageing issues and initiating
programmes for the welfare of the aged, particularly
since the government has limited resources and
requires support in reaching out to the needy section
of society to enhance the facilities in existing and new
age-care institutions.

The last scene
MOHAMMAD TAUB

EVERY society marks the biogra­ worn out and removed from the cen­
phical trajectory of its members into tral concerns of active, healthy and
recognized scenes of a play. Each productive life.
Old age, viewed integrally, is
scene represents different roles and
narrations, varying colours and cos­ understood as a repository of age-old
tumes. As individuals graduate from wisdom and cumulative experiences.
one scene to another, they acquire Viewed thus, old age gets metaphonewer identities and relations in the rized and embellished with respect
■ and vital resources necessary for pro­
structure and dynamics of the play.
The imagery of drama is some­ ductive life. Seen as a single slice of
what restrictive if deployed to under­ life unconnected to its other phases,
stand life. While a play has clear cut old age is often burdened with ageism,
scenes, actual life has several replays construed either as a second child­
of the same drama enacted simultane­ hood or mere oblivion - in the words
ously. The final, the middle and the of Shakespeare ‘Sans teeth, sans taste,
early scenes of a play coexist in actual sans everything' (As you like it, act 2,
life; it is their inter-relation which scene?).
All societies evolve an intermakes a scene or a group of actors
generational contract - between the
problematic.
The last scene in life has invari­ generation now retired having lived
ably been understood either segmen- its productive life, those in the protally of integrally. In a segmental ductive segment, and the ones in the
view, old age is set apart, constructed pre-productive stage. The intergenethrough stereotypes and discrimi­ rational contract, implicit yet symbolnated against, simply because those ised in cultural narratives, foregrounds
enacting the last scene are considered interdependenceand exchange of life

■

51
!

SEMINAR 488 - April 2000

»

Rarely does the dominant con­ tain sequence of a performing art, dis­
support provisions in material and
symbolic terms. While no society can sciousness of the productive segment playing grace and elegance. The task
claim that it follows the contract in ’ of society display an ability to step of retrieving the charm requires a
its full details, its breach generates back and examine its basic premises. vantage point located in movement
ambivalence and is rarely justified in Ironically, the vantage point for of poise and not haste. While haste is
self-reflection comes from its own invariably unmindful of its context,
clearterms.
counterpoint - old age or childhood. poise always depends on the fit with
the surroundings. This is also the dis­
The Puranic story of Shravan Kumar Alternatively, productive humanity is
forced into introspection in moments tinction between the young and the
provides one example of a sacred of colossal failures. Moments of break­ old. Today much of the reality of old
rationale for a mutual sharing of life down offer material to look at con­ age remains under-represented.
resources between the post productive stituent parts holistically, integrally
and productive members in a family. and without imposing segments or The present note turns to selected
The story glorifies the relevance of contending divisions on common
writings in Urdu fiction to understand
and relation to old age and develops humanity. By itself, productive huma­
the age-old aspect of old age. This
the logic to a point where, in the act nity views old age in its own image
literature sensitises us to the need
of serving the old parents, Shravan and suggests remedial measures
counter
ageism and to examine t.
Kumar and his wife not just lose their accordingly. For instance, most stu­
biography
of the old in their own terms.
precious material possessions but dies on old age in India, backed by
Kashmiri Lal Zakir’s novel
even their lives. The story, however, western perspectives in gerontology,,
invariably
evaluate
old
people
along
DoobteySoorajKiKatha
1 (Thetaleof
resolves the tragic ending by relating
measures
of
consumption
(life-supthe
setting
sun)
pastes
a
poetic
adage
the happening to di vine will.
at
the
beginning
of
the
story:
Old age thus becomes part of a port systems) orproductivity (gainful
Two fellow travellers, the sun and
sacred cosmos which in turn stren­ work).
me/Had reached our station in the
gthens the intergenerational contract.
evening./Both were travel weary,
The story further contrasts Shravan l\/larket mechanisms often be­
slept on the earth’s mattress/Next
Kumar with his counterpoint Damomorning the sun woke up and left
come
the
cultural
matrix
in
planning
dar who treats his parents as the bur­
me in my sleep.
densome junk ot his life. Shravan remedial actions. But one may relate
The poem captures the break­
Kumar carries his parents around in a to old age through resources of life
down
in the intergenerational agreekanwar (a bamboo device shouldered outside the state or the market, and
by pilgrims for carrying their belong­ locate the old, not as recipients of ment, paving the way for the creation
ings) in search of acure fortheir blind­ societal philanthropy but an authen- of humanity left in the lurch. In the
ness by visiting holy places. Damodar, tic section of humanity capable of preface of the novel Aao boat karen
on the other hand, drives his parents providing vital inputs to life in the (Let’sTalk) the author argues that e? ’
out of the house as he perceives them making. In its own life domain, a large fragment of life has a beating hea
chunk°of humanity is constantly He uses the metaphorofa mother and
a useless dead weight.
child. Though the growing child cre­
In our society of mega projects glossed over or dismissed by the
ates difficulties in communication and
and transnational corporations, the dominant spirit of working people.
relationship, the motherrarely forgoes
There
is,
however,
a
manner
of
retri
­
ancient intergenerational agreement
eving
or
harnessing
life
expressions
her responsibility. ~
Even iin moments
seems to have broken down in favour
and
resources
dismissed
or
pushed
when
she
cannot
attend
to the child or
of the productive and professional
into
oblivion
out
of
sheer
haste.
even
comprehend
it,
the
frame of the
segment of society. Consequently,
One glimpse of the lost reality of relationship is not transgressed.
while the post productive segment
r stillingAs the child climbs
the stairs of
old
age
can be gathered. by
-----------------------------slides into crass old age, the pre pro­
ductive begins to suffer from child the image of an old man bending down life, the mother gradually steps down
to pick-up his walking stick.
For aL the same ladder. While the child grows
■ ■ abuse. Is it because the rhythms of
moTnent ignore the intention of the under the spreading light of day, the
productive life are so focused and
52 engaged that they neither have the old man in bending down as well as
time nor predisposition to look at the the walking stick. What is left is a 1. Kashmiri Lal Zakir. Doobtey Sooraj ki
Katha, Novelistan, New Delhi, 1985.
scaly margins of collective humanity? movement of the body as if in a cerAgeing

.. ,

mother’s canopy of sunlight slowly
recedes. Though they converse with
each other, there is a hiatus of several
stairs of age between them. Both
struggle to understand each other, but
with effort and difficulty. And as the

ladder of life between them grows,
their communication suffers. There
comes a point when the son stands on
the highest point of the ladder and the
mother on its lower terminal end.
Communication between them is now
near impossible.

The distance makes their voices

I

inaudible toeach other. One is in haste
and has no time to listen to a long nar­
ration. But the mother is reticent.
She sees no reason to be in haste be­
cause the final stairs disappear into
nothingness. She is reminded of the
time when her son would cry and even
if the cry was incomprehensible she
never opted out of the grid of commu­
nication. Now. when the mother slips
on the stairs, she is overshadowed by
a setting sun, and the son is looking
elsewhere.
This precariousness of relations
between two generations becomes
the dominant theme of the novel. The
life of Durga Das, the protagonist, is
traced from youth to old age. The
novel juggles with the dilemma of
locatingthe aged-in the family or in
an old people’s home. The authoropts
for the family. Perhaps the novelist’s
sensitivity grounds the remedy in the
expressive resources of the family and
not the stark instrumentalities of the
market of which the old people’s home
is one expression.
Can one simply break intergenerational relations? Perhaps not.
Joginder Pal’s Maqaniaf- (Stations)
describes Jamal’s encounter with
various contrasting stations (as gene-

2. Joginder Pal. ‘Maqamat', Naya Daur. Sep­
tember 1996. pp. 27-30.

rational points) of his biographical
journey. Jamal, in his mother’s lap,
learns to recite the word of God and
w,akesupintotheworldofinsightand
meaning. But in the next stage, when
Jamal’s children are growing, his
mother is beginning to lose her bearingsin life.Sheisphysicallyand mentally challenged. And when she beats
at her locked room in anguish, Jamal
chooses to sedate her. Was this the
quickest and leastexpensive remedy?
Jamal gets the first clue to his moth­
er’s angst when his son, after mar­
riage, pronounced that he wished to
lead his life (with wife and children)
in his own way, unencumbered by
the old parents. Jamal now has the
answer: his mother needed him, not
the pills. He explains to his son how
love for wife and children grows only
ifithasawiderconstituency,thatlove
for one’s wife grows alongside love
for one’s parents. ‘Please include Us
in yourWe,’ Jamal implores.
But Maqamat’s characters encounteracomplex principle of inclu­
sion and exclusion among members
in a group. Jamal mistakes his wife
for his mother. Why this inclusion of
his mother after her complete exclusion? Perhaps continuities in primary
relationships, when partially blocked,
display a reserve and resilience to
reappear in multifarious forms independent of the actor’s will. These
relationships offer material for imagining a more sensitive blueprint for
the inclusion of the aged in the community of the young,

I
Indeed, there could be yet another
way. The story Nannhi kiNaani3 (The
little one’s grandmother) by Ismat
Chughtai describes an old woman
who in a small town of some zamin3. Ismat Chughtai. ‘Nannhi ki Naani’. in Asif
Nawaz Choudhary (ed). Ismat Chugtai ke Sau
Afsaney, Maktaba-e-Shero-o-Adab Lahore.
n.d.,pp. 1294-1308.

dari settlement had served as a maid
to the families of the local elite ever
since her childhood. Her salary consisted of the day’s meals and clothes
discarded by the family. She was
forced to retire when shecouldn’t spot
a lizard in thedaaland a fly in the rotis.
After retirement, she tries to carve out
a niche for herself. She becomes a
mobile prop in agiven cultural setting
and plays the role of an information
conduit/carrieramong families where
she wasafamiliarpresence.

E

fc^conomically she was assetless
and entirely dependent on her past
patrons. Yet, she overcame her mar­
ginality by seeking membership in a
common cultural universe. She is let
in and accommodated. There was an
ethos wherein she was assigned a
position. For instance, everyone knew
that she pilfered household articles,
or demanded hospitality when the
choicest food was cooked in limited
quantity forspecial guests. She would
entertain, embarrass, criticize, help somehow succeeding in over-coming
her marginality. There were sufficient
fragmentsofbothcultureandrelationships to which she had access. The
story evokes the elan of a civilizational principle which binds the
engaged and the retired without gratuity or regular financial support.
But Nanhi ki Naani ends tragically. thereby revealing the fragility
of cultural resolution. Asimilartheme
in a different setting is charted out in
Hajra Kumar’s Mohabbut, Kitab A it r
Tokrey* (Love, books and baskets), the
story of Master Shanker Das Nigam
whose ageing happens coterminously
with several other events in a small
town. Master Nigam was fiercely fond
of his rare books in Urdu and Persian,
a passion not shared by his wife or
anyoneelse.

4. Hajra Kumar,‘Mohubbut.kitabaurtokrey’,
Biswin Sadi. April 1996, pp. 51 -55.
SEMINAR 488 - April 2000

53

He had not even deposited emo­
tions in the family bank. As the coun­
try was partitioned and zamindarii
abolished, Master Nigam’s sons grew'
into marriageable age. Meanwhile, his
wife dies and he gels furtherconfined
to his idiosyncratic past. The memory'
ofa platonic love is not enough to alter
the solitariness of his life. Subsequ­
ently, when the sons get married, Masteris furtherestranged from his family.

gonist refuses to vacate her ancestral slowly frittering away and so was she.
home to shift to a government quarter When she died, the first of her kin to
allocated to her grandson. When her spread the news was the dog who vis­
grandson suggests that he would let ited Dadi every evening forhis meal.
out the parental house on rent, Dadi
JoginderPal’s Dadiyan helps us
disagrees with him. She tells him that to understand the nuances ofdisplaceshe will not leave the house alone, that ment in society. Is compensation ever
if it is to be rented out, she too should possible for a life lost? How can one
be included in it. To give a further provide a substitute for the house in
punch to her views she says, ‘If the old which Dadi had spent her entire life?
are of no use, rent them out.’
What about the villages and tribal
What was so special about the lands which our policy makers cog­
house which Dadi was defending so nize as just a simple piece of land?
■ w iaster s esoteric engagements fondly? It had nine little rooms, three
How can there be a simple substitute
irked everyone in the family. At least of them without a roof. The other
for a life whose complexity is unfath­
in the past his wife would dry his damp rooms were in no better shape. But
omable to an outsider? One reason
books and the.pickles under the sun when Dadi opted to stay back, she
why solutions to the problem of age
in acommon stroke. But with the pas­ wasn’t left alone. She found herself
ing cannot be meaningfully locate
sage of time, both Master Nigam as waiting for her own self as she moved
in only making the elderly eithergood
well as his chosen col lection of books from one room to the other. In one
consumers or good producers is be­
lose even their notional significance. room Dadi found herself cutting
cause production and consumption
Once when he is away for a Ions vegetables, in the kitchen blowing
do not exhaust all realmsand realities
period his room is thoroughly cleaned the fire, in yet another resting on the ofahuman being.
and decked up for Di wali. The termite- bed, expressing concern.
eaten books and the wooden frame
I n attempting to retrieve the age-old
of the almirah are washed away. The The various dadis formed a moral
'worn out' books. Master Nigam’s
from old age, an integral view helps
simulacra, are, however, rejuvenated community deposited in a robust and restore the linkages between post
in a curious manner. Mixed with animated fashion in the seemingly
productive and productive segments
water and clay, the old books are con­ dilapidated ancestral home. Not only of society. This view also recreates the
vened into a soft paper mash to make did Dadi’s ego lend itself to a plura­ centrality of mutualism in collective
baskets for storing onions and pota­ lity of alters, she even found herself life. One last clarification about the
toes. Master Nigam can’t come to merging into the inmates of the local age-old in old age: Its constituents
terms with the cataclysmic changes environment.Thelargerkinshipstart- cannot be seen as mere functional
and passes away. On the 13th day ing from Dadi included koel, a fre- inputs into an inter-generational comafter his death, 13 Brahmins are fed quent visitor, which she named Kesri bine. They incorporate a capacity tc
with the customary delectable eatables and a host of house sparrows who offera critique of the dominant order,
stored in the paper-mache baskets.
had built theirnests
in the
house. Ano( " the
' ways of the productive workins
--------------------------- - of
Is utility and productivity the ther long term resident who formed segments. This capacity is a repository
only reference point for declaring an part of Dadi’s practical kin was a of ultimate knowledge, though unreobject or a habit obsolescent? Who is king cobra. She had fed him a bowl cognized by the rule of fashion. It
tojudge? Who is labelled? How do the of milk every evening from the time generates another form of knowledge
labelled respond? Perhaps piecemeal she became a member of the house to understand one’s relation to the
policy offers a restricted answer. For after marriage. Dadi was Kesri as also limits of life; also the datedness of
inviting a long term civilisational the mango flowerwhich she picked at prevailing meanings with claims to
response to the query, one would draw onset of summer.
perenniality. In its ability to carry a
attention to Joginder Pafs Dadiyan5
The mindscape and the land­ memory/record of how life was, old
(Grandmothers) in which the prota- scape were part of a common being. age confronts adulthood. It provides
Dadi, along with an entire milieu grew, a powerful critique to alter the meta5. Joginder Pal, ‘Dadiyan’. in JoginderPalke
matured and experienced ageing in a phors/the stereotypes which seek to
Afsanon ka Iniekhab, New Delhi.Takhleeqkar
Publishers. 1996. pp. 90-100.
common frame. Dadi’s house was lock old age in a fixed position.

M

54

Ageing

■

1

-----

Omission-commission
WITH time things change. Seasons change, nights
change. Twelve miles away speech changes. How
much is in the head, has anyone weighed it? One hopes
to God that no one loses their head.
In a village waving in the breeze, lived Bania. A
sweet grandson was born to him in late age; birth was
in Moola nakshatra (the first star of the Sagittarius).
So both his parents died when he was seven months
old. The mother died first, then the father. Who can
say what is going to happen? When the only son dies,
grief is not ordinary. When Sethani saw her only son’s
dead body, she wept and wept and died. But Seth
considered these events to be the result of his karmcr,
he took courageous action.
Clasping his grandson to his breast, he continued
to run his business somehow... and no one will know
how he did it. Grandfather loved his grandson more
than hisown life; the child stuck to his lap twenty-four
hours a day as though he was part of the same body.
When the child would cry, grandfather would do what
he could to stop the crying. He would make him drink
* Bhul-chook leni-deni by Vijay Dan Detha and Komal Kothari.
Transcreated from the Marwari original by Mohmaya.

milk; when the child insisted, he would walk on his
knees. He became a horse to ride on... he would be
beaten lightly with a whip. At night he would sleep
on the wet side of the bed while the child slept on the
dry side... and even in his dreams he did not get
repulsed by the child’s drool, shit and piss.
As he started learning to walk, the child began
asking questions in his lisping way. In the middle of
the night he would ask what is this and who says what...
and grandfather would answer each question with
enthusiasm. He would explain everything... he would
be asked once, he would be asked thirty times. He
would laugh and answer in sweet and mild tones.
He would never make the child wait for an answer, or
give another answer. He would not be anxious or
angry, but explain with fourfold enthusiasm as though
he was the questioner himself. As though each ques­
tion was a new question. He would relate long for­
gotten memories to his grandson. What is this-acrow.
What is this - chandamama (moon). What is this - a
peacock. What is this -a tree. What is this - neem.
One day during the monsoon, grandfather was
explaining the meaning of loss and gain to his grandSEMINAR 488 - April 2000

55

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56

son when lightningand thunderstruck with great force.
The child became frightened and cried, ‘Which bad
asked whoTj^c banSed Ille door shUt; grandfather
times do I have?oTenS°nbCCanleang,7:‘H0Wmany
man is fighting with whom?’ Grandfather soothed
him and replied. This bad man is mad, he is constantly
nderstand it once" Why
‘
fighting with everyone and roaring and glittering for
name now... why should
J°U S'art rec,ting SOdS
twenty-four hours. But we don't care about hinV He
sethhesiX:XLy‘hsse/roncen,you?;
then put cotton balls into the child’s ears. After this
meaning has been erased from
incident, he would put cotton balls into the child's
dies al I relationships cannot be broken off. I have'teen
ears every monsoon.
wanting to say something to you for a long time. If I do
Once during the rains a frog hopped near the
not say it now, it will remain forever in my heart ’
child. He pointed to it, what is this-a frog. What is this
Grandson replied with irritation: ‘After death
- a frog, a frog. On the third repeat, grandfather started
how can anything remain in your heart?’
tocough... the chiId continued toask what is this, what
Grandfather coughed and coughed ‘.. .son you do
is this, but grandfather could not form the word ‘frog’
not even have time to listen to me. But I had all the time
fully. He coughed so hard that he became exhausted.°.
to give to you. Don’t be so angry. You would ask me a
khalkhal, khalkhal... till his guts started to hurt eyes
question twenty, twenty times, and I would answer
started to water. But the child’s attention was stilfon
you immediately. And now you are upset when I ask
the frog. In between coughs, grandfather managed to
you something twice.’
rasp out fiog - In the child’s happiness lay his own.
‘So should I leave my work just for you’, ans­
While making bills in his shop, while weighing
wered son. ‘I too would work’, said grandfather. kBut
items, he was asked what is this? What is this? Notonce
more than my business, I looked after you. Now you
was he miserly with an answer. What is this-ant. What
are big. but when you were a child I would consider
is this - elephant. What is this - lamp. What is this your piss of more value than gangajal. I did not even
sun. In the light of the moon, the lamp, the sun, grand­
dream of being treated like this. Once in the monsoon,
father taught grandson all that he needed to know.
frogscame into the waterof the courtyard... you asked
Explaining, explaining, Seth became old. Grandson
what is this? While saying the word frog I started cou­
became a youth. He was married with much song and
ghing, and coughed so much that I thought I would die.’
dance. His wife entered the house, rimjhim rimjhun.
‘What nonsense!’ said grandson angrily. ‘Is it
Grandfather’s birth became successful, but his
possible that I did not even know a frog? You have noth­
body became old and weak. Teeth dropped out, hair fell
ing betterto do than accuse me falsely.’
out... his neck began to shake and illness began to stalk
Laughing his toothless laugh, grandfather
him. Every nerve became filled with weakness...
countered: ‘False accusations? Would I lie to you? In
cough fever pain anxiety... if god would only take me
business the supreme quality is of ommission-commisnow, then my breath can leave my body. But death does
sion... I now ask you fora favour. Ybu cannot refuse
not come soon and one must bear ones sorrows. His
me. When you have children you will understand the
eyes became dim, ears could not hear properly.
true meaning of return-favours.’ Grandson was in a
All through the day and night, grandfather’s
hurry, he was not inclined to wasting his time in such
cough would disturb the sleep of grandson sleeping
talk. ‘Butl have nevertaken any favours,’ hesaid.Seth
beside his wife. He would be upset, but hesitated to
spat out phlegm and replied: ‘The mistaken favour was
scold him; he would admonish him many times, but
all mine and it is my biggest mistake that I am in your
grandfather could not control himself. Until his eyes
care today. Now I have had enough... while dying I
gave away, he would wipe his spit and phlegm with his
give you my blessings-may you liveathousand years.
own hand... but when he became blind, he could not
May there always be children’s voices and laughter in
0 this. He would wipe his drool with the end of the
your courtyard. And when the time comes, may your
h" ?’Y^ho would wash hisclothes, who would bathe
children treat you exactly in this way. Like you, may
im • randson and his wife were young, they themthey never acknowledge return-favours. I hope I die
se ves were blind. They did not care. And then the busi­
now... goplay thedrum in happiness.’
ness accounts had to be kept and maintained... no one
Seth reached the end of his lonely life. Was his
cou ta e time off Qnce he beard the sound of the door
grandson happy? Only he knows that himself... but to
opening... he called out who is it? Granijson did not
keep up appearances he wept loudly and kept weep­
hkethequestion and answered sarcastically, ‘It is me’.
ing long after the ceremony was over.
Ageing

r

Books
SOCIAL AGING IN A DELHI NEIGHBOR­
HOOD by John van Willigen and Narender K.
Chadha. Bergin and Garvey, Westport, Connecticut
andLondon, 1999.

THERE is no dearth of popular and academic articles
and books on social ageing. Most of them are based on
impressionistic findings and a few unstructured inter­
views with haphazardly drawn respondents. Having
tended their aged parents and grandparents or some
other kin, thereby experiencing the traumas of ageing,
many authors claim to have an understanding of the
problems and crises of the ageing population.
No doubt, a keen observer can gather important
insights from the study of even a single case, and
anthropology has a tradition of writing and analysing
life history accounts of typical individuals, thus
advancing inductive statements. Even general impres­
sions of a phenomenon can be hypothesis-generating
but the basic canon of sociological research is to focus
on acommunity, either naturally given or ‘constructed’
by the researcher, before formulating propositions
about the phenomenon.
van Willigen’and Chadha, the former an Ameri­
can anthropologist and the latter an Indian psycholo­
gist, have in their book which appeared in the
International Year of the Aged Peoples, ‘constructed’
asampled community of olderpeople. They carried out
an intensive study, relying both on qualitative obser­
vations and quantitative analysis. Extremely well writ­
ten, this Indo-American venture is a valuable addition
to the literature on social gerontology and anthro­
pology of ageing. It is also a good contribution to
urban sociology.
Both van Willigen and Chadha have indepen­
dently worked on ageing. Earlier in 1995 Chadhacompleted an ICSSR sponsored project on the problems of
older people in Delhi, while van Willigen authored a
well-known work on the social organisation of older
people in a rural American community in Kentucky,
USA in 1989. They met accidentally at the venue of
the Indian Science Congress in Poona in 1988, and have
since collaborated at researching and understanding ”
social ageing in a North Indian city, resulting in sev­
eral oft-quoted articles, and the book under review.
The authors conceptualised their division of
labour as ‘dialogic’ since theoretical and epistemolo­
gical differences exist between anthropology and

psychology. They have chosen to explore a ‘middle
path between the tendencies of [the] two disciplines’
(p. ix). Being a psychologist, Chadha takes responsi­
bility for handling the complex statistical measures.
Being an Indian, Delhite, Punjabi and a native speaker
of the languages spoken by the ‘community’, he con­
ducted the interviews, though van Willigen too partici­
pated in about a third of them.
Anthropologists are committed to placing culture
traits, social institutions, customs and practices in their
relevant contexts, to gauge the ‘within’ meanings. This
is what van Willigen does best. His Kentucky ‘com­
munity’ of older persons is often compared with the
Indian counterparts. The authors offer a commentary
on certain interesting similarities and differences
between the two situations, conscious of the qualita­
tively different social worlds. For instance, the size of
the primary groups of older people in both Kentucky
and Delhi is similar.
Both authors agree that the theoretical under­
pinning of Indian gerontological research is poorly
developed. Clearly, Indian scholars often make a
wholesale application of a theory developed in the
West without thought to its relevance and context in
India. This ‘mimicry’, as the authors describe it (p. x),
suppresses the specific (i.e. cultural) characteristics
of the local situation, the specific strategies the people
adopt to survive in a particular milieu. This leads us to
think that despite cultural differences people respond
similarly to the predicaments of life and society.
Social researchers have time and again exploded the
myth of human generality which is created at the
expense of particularity. Theory is best grounded in
empirical reality.
The authors' theorising draws on their dialogue
from the vantage points of their respective disciplines
and cultural backgrounds. Their approach to theory is
inductive; they move from the findings of empirical
research in Indiatocertain general propositions.
Social ageing refers to the changes in the content
and meaning of peoples’ behaviour and expectations
overtime. People take adaptive decisions with the pas­
sage of time to ensure theiroptimum survival. Thecontent of such decisions, as also the resultant sociological
context, is determined by their culture. Social ageing
should be distinguished from biological ageing - the
former is a cultural construction of the inevitability of
the latter process.
SEMINAR 488 - April 2000

57

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engage, they may even invite vituperations. The norms
may be relaxed for the disengaged; so also the expec­
tations from them. Certain cultures (like the Indian)
place high premium on disengagement, describing old
age as a return to infancy and old people as ‘children’
{burhabaccha eksaman). Just as norms and sanctions
are relaxed for children, so are they for the aged.
One consequence of disengagement is that the
individual becomes less vertically integrated with
people of other (younger) age groups. His integration
with his own age grade, horizontal integration, could
certainly be far greater. This explains the success of
several senior citizens’ associations. Through disen­
gagement the individual adapts to the two facts of life:
the gradual decrement of strength and the expectation
of death. Disengagement prepares a person to face his
’mminent departure. Disengagement theorists believe
that theory is universally applicable, though mediated
by culture. Equally, gender responses to disengage­
ment are highly variable. In India, for instance, older
women are less disengaged in comparison to their male
counterparts.
Although severely criticised, disengagement
theory stimulated substantial new research and analy­
sis, as also the development of alternative theories
relating to social welfare and geriatric practices. One
of them, ‘activity theory’, which argues that success­
ful ageing is contingent upon continued activity. If
old people continue to work, remain preoccupied with
activities, they will have greater life satisfaction, will
not suffer from role loss, will have something to look
forward to, and will remain integrated in society, both
vertically and horizontally.
More than test disengagement theory, van
Will igen and Chadhaexamine the lives of north Indian
old people from the perspective of the various themes
in an effort to constitute a theory of social ageing. They
identify the cultural institutions that ‘influence and
provide meaning to social ageing processes’ (p. 18)
such as asrama (the vocations of life), varna (ritual
ranking based on ascriptive categories), purdah (veil­
ing, indicative of female seclusion), and the joint
family pattern. It may be noted at the outset that the
institution of varnasrama is essentially Hindu. ItsJ
utility, therefore, in understanding social ageing in
other religious communities is doubtful, although they
too value disengagement from worldly affairs.
Crucial to an understanding of social ageing in
Hindu communities (and the authors worked chiefly
with north Indian Hindus) are the institutions of
purusartha (the ‘aims of life’) and«5ra/7z<7 (the ‘stages

of life’). The former is a theoretical delineation of what
humans should do, the meaning of theirexistence, how
they are different from animals {dharma), how they
should reproduce their own kind and the society {kama
and artha), and how they should ensure their perma­
nent release from the incessant cycle of birth, death and
rebirth {moksha). The theory ofpurusartha offers a fine
coexistence of the ideas of materialism and spiritual­
ism; in the hierarchy it aims, moksa occupies the high­
est place and kama (carnal satisfaction) the lowest.
Purusartha finds a concrete expression in the
practice of asrama, the vocations of life. The final
release (of soul and its merger with the supreme soul,
the paramatman) is possible when one renounces the
world {samnyasa) after having disengaged oneself
from the social world (during the third stage of life
called vanaprastha). van Willigen and Chadha explore
the relevance of this cultural model of engagement (in
the vocations of celibate-student and householder) and
disengagement (in the vocations of forest-dweller and
renouncer) to the people in contemporary urban India.
However, it must be remembered that thepurusarthaasrama vyavastha (organisation of aims and stages of
life) is relevant essentially for males of the Brahmin
caste. Historians of ancient India point out that for the
Kshtriya males death in the battlefield represented
salvation; in other words, purusartha for the Kshtriya
and Vaishya was different from what it was for the
Brahmins. Disengagement had a different cultural
content in different communities: going to the battle­
field (often dressed like a renouncer) was symbolic of
disengagement from the social world.
van Willigen and Chadha carried out their study
in an upper class neighbourhood of Delhi, RanaPratap
Bagh. We do not know how they determined the class
position of their respondents: Was it subjective, that is,
based on how people described themselves in class
terms, or was it an objective assessment? The survey
data was drawn from a systematic, random sample of
people (53% men and 47% women), 55 years and older
(the age-range of their sample was 55 years to 90 years,
the mean age being 65.6 years), through open-ended
interviewing, participant observation, and a review of
documents. Ethnographic research was carried out in
the community as a whole. However, they do not
specify which activities of the community they partici­
pated in, since they used participant observation as
one of the techniques of datacollection.
The chapters ‘The Household and Social Ageing’
and ‘Networks: the World Beyond the Family’, pro­
vide a sophisticated analysis of the data collected. The
SEMINAR 488 - April 2000

59

V

3

60

former chapter analyses the social life of the aged
people in the context of their households, the problems
they face and their responses to them. It describes the
nature of integration that older people have with their
families and households. The chapter on networks
focuses on the integration of the aged with the exter­
nal world.
van Willigen and Chadha used ‘interaction fre­
quency categories to produce the list of persons that
made up the network’ (p. 120). Neighbours formed an
i mportant category of networks. In women’s networks,
there were more neighbours than was the case with
men. Friends were the other component of network men had more friends than women, indicatingthat they
participated more in extra-domestic realms than the
women, whose social world was confined largely to
the household. The older people, mostly men, also par­
ticipated in several associations, such as trusts and
charitable societies, religious study groups, card play­
ing groups, informal conversational circles, kitty par­
ties (mainly women), worship groups, devotional
singing (kirtari) groups, political parties, and street
organisations.
Unlike expectations based on exchange theory,
persons with smaller networks did not come across as
healthier than others. They had lower incomes and
exercised lower control over their worlds. They were
also less satisfied with their lives. The mean network
size of those who were placed in the rung of ‘low sat­
isfaction ’, in the 1 ife scale was 21.6; those classified in
the ‘high satisfaction' rung had a mean network size
of 30.7 individuals (p. 134). Successful ageing requires
a network of at least 25 individuals. This in turn is
dependent upon material wealth, power relations,
and degree of control over life.
These networks perform several functions; in
particular by providing a group with which the indi­
vidual can share grievances and frustrations emerging
from the household. For instance, a widowermay come
home after severely criticising (and thereafter feeling
‘light’) his daughter-in-law in his conversational cir­
cle, and thereby find an outlet for his frustrations!
Successful ageing is a function of health, power, and
social involvement. It also depends upon the commu­
nity ecology: if the community is homogeneous, there
are greater chances for the emergence of mutual sup­
port associations.
However, gender distinctions are crucial, van
Willigen and Chadha argue that power structures
associated with the patrilineal, patrilocal, and patriar­
chal joint families constrain the ability of females to

achieve successful ageing (pp. 138-9). Also, the con­
trol women exercise overtheir environment and house­
hold varies with age. A newly-married woman is
powerless in a patri-joint family; yet she may get her
way by using negative strategies such as crying,
expressing displeasure, getting angry, refusing to
speak, denying sex to her husband, and so on. By com­
parison, an old woman (the mother of grown-up sons)
can get her decisions implemented in a positive
manner - by relying on respect for age, or by operat­
ing through the medium of her sons and grandsons.
Women enjoy invisible power in joint families;
they differ in how they exercise it. Most observers
hypothesize that women are more easily able to adapt
themselves to the demands of the household, particu­
larly through daughters-in-law and grandchildren, than
men; this may explain why widows are more integrated
within households than widowers. Studies focusing on
genderdifferentials, ageing, and power might provide
answers to these questions.

Vinay KumarSrivastava

THE FIRST FIVE YEARS: A Critical Perspective
on Early Childhood Care and Education edited
by MinaSwaminathan. Sage, Delhi, 1998.
THIS book is a must read for all those who consider
themselves to be educators, particularly those who see
education as a lever for societal change. For those of
us who sit in urban isolation, far from the rural reality,
it is as if ‘turning and turning in the widening gyre the
falcon no longer knows the falconer’ (Yeats, The Sec­
ond Coming). The commitment and dedication of those
who have set up the various ECCE programmes gives
a new tilt to the words that management gurus claim
always go together, ‘leadership and management’.
Since the success of the projects described in the
book is directly related to the quality of community
participation achieved, one wonders whether manage­
ment has any role at all to play in evolving leadership
models.
The first part of the book is a veritable cornuco­
pia of indigenous, educational endeavours packaged
in the various case studies and moulded to shape and
suit diverse terrains, people and sensitive local issues.
Each of the cases discussed are un ique and inspirational
like the Mobile Creches programme and the tale of
Ambapali which introduces the NGO-govemment
interface, or the Integrated Child Development Ser­
vices programme run through Urmul. The story of how

Ageing

’.....^sr'

--■fit

___

SEWA, through hard work and dedication, gave birth
to Shaishav which in turn empowered the women of
Kheda district is of great significance. Equally illumi­
nating is the excellent community-based model of a
pre-school programme developed by the Palmyrah
Workers’ Development Society in theTirunelveli and
Kanyakumari districts of Tamil Nadu.
In an environment conditioned by media focus
on lost causes and sensationalism, the warmth and posi­
tive flavour that pervades The First Five Years makes
the book an inspirational heart warmer. This is espe­
cially relevant at a time when the Budget 2000 is out
and the government has once again seen fit to increase
allocation for Human Resource Development by a mi­
serly .09% from 3.23% to 3.29% while increasing
defence allotment to a whopping 19.51 % of the plan
outlay. The Probe report (OUP1999) provides histori­
cal evidence of our government’s continuous make­
shift treatment to education over the years. Clearly yet
another age is to go by before we focus attention at the
marginalised in our country, the women and children
in particular. Despite the Budget 2000 continuing this
skewed vision we have no cause to despair, particularly
if we believe the message in this book: The meek will
yet inherit the earth I
The book is divided into two parts. The first part
offers a micro perspective through documenting eight
innovations in early childhood care and education in
India; the second provides the macro perspective
through six state of the art essays on the current status
of ECCE in the country. The first two essays of part two
provide the main background against which most of
the other material presented can be viewed, especially
the first eight vignettes. Margaret Khalkdena’s essay,
titled Early Childhood Care and Education in India,
presents a historical perspective, tracing the develop­
ment of ECCE in all its various colours and dimensions
- from the early 17th century, through the colonial era
and the introduction of the primary school system by
the British, into the post colonial era, the framing of
the Constitution in 1950 and in particular. Article 45,
‘The state must endeavour to provide free and compul­
sory education for all children until they complete 14
years of age’ (p. 168). Khalakdena traces the evolution
of organized thinking on ECCE. She points out how
the government has constantly shifted its stance on
ECCE, never quite sure of where it wants to go. ‘The
subject of child welfare seems to have been appor­
tioned an irregular staccato rhythm which could per­
haps be expressed in the words: start... halt... shift...
restart’ (Luthra, 1979).

It was subsequent to the Fifth Plan that the gov­
ernment realized the importance ofcommunity partici­
pation and changed focus to supplementing the family
rather than supplanting it (Myers, 1992). Khalakdena
also highlights the stellar work by the voluntary sec­
tor and points to its spirit of dedication, commitment,
teamwork, closeness to community and its continuous
efforts at evolving new strategies based on the needs
of the situation despite low remuneration in the sector.
By comparison the private sector is characterized by a
lack of vision and understanding about the needs and
psychology of the pre-school child. What it offers can
best be characterized as ‘care shops’ (p. 183) - places
to prepare children for admission into the competitive
primary schools.
Vinita Kaul points out how the growth of the
ECCE movement showed that in the absence of appro­
priate and adequate training of teachers and workers,
one could be left with a pre-school curriculum that is
both ‘child unfriendly’ and ‘burdensome’. She analy­
ses the existing training programmes, highlighting the
problems faced by the trainees who pass out from the
Nursery Training Institutes, particularly vis-a-vis lan­
guage. She also juxtaposes the one/two year teacher
training programmes with those specifically offered by
the various ECCE experiments, such as the training
module for the workers of the Mobile Creches pro­
gramme. The Mobile Creches offers an integrated
programme which includes a creche, a balwadi, nonformal education and adult education.
Francis Sinha focuses on ways to appraise the
cost effectiveness of child-care programmes. She
points to the differences between ‘effectiveness’ and
‘efficiency’, particularly in programmes which value
the human quality both in terms of the teacher/worker
as well as the learner/beneficiary. ‘A programme is
efficient if goals and objectives are achieved at a rea­
sonable cost’ (p. 211). To overcome this point, Sinha
suggests methods of analyzing cost-effectiveness in
quantified but non-fmancial terms by linking effective­
ness to programme goals and objectives. An extremely
interesting essay, especially for those who would like
to use available resources in a disciplined manner to
get maximum mileage.
All the case studies explore the interface between
women’s empowerment and child care. Rajalakshmi
Sriram’s article provides a perceptive and detailed
analysis of this interface, complete with historical per­
spective. She correctly points out that in order for the
empowerment process to take place among women it
is necessary ‘that women find time and space of their
SEMINAR 488 - April 2000

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61

own to re-examine their lives critically and collec­
with special reference to Kerala. The authors indicate
tively’ (p. 224). Child care facilities not only give
that the states of Kerala, Tamil Nadu and Punjab are
women the much needed time and space for introspec­
likely to experience a rapid increase in their old age
tion but also permit them to work both without anxi­
population in the coming decades. The demographic
ety about the welfare of their child, and thus increases
transition coupled with various socio-economic
their incomes and self-esteem and standing in the
changes, would drastically impact the lives of the eld­
family and community.
erly. The book draws attention to the emergence of
The subsequent overview essays lend further
nuclear families, smaller number of children per cou­
depth to the various case studies. Each essay is a stand­
ple, greater longevity, physical separation of parents
ing testimony to the dedication of the voluntary sector
from adult children as a result of rapid urbanization and
in particular through the vision and leadership of indi­
age-selective rural-urban migration, which alters the
viduals, who are largely women, in transforming the
dynamics of relationships between old and young
lives of women and children in the rural sector. The
generations. The discussion takes note of low literacy
case studies that discuss the problems faced by projects
levels, marital status, economic situation and living
involving government and voluntary sector coopera­
arrangements of older persons. In this context the
tion shed further light on the issue of cost effectiveness. ■ authors assess the future size and composition of the
It is clear that wherever the human element is impor­
elderly society as well as their needs and the difficul­
tant part and the programme concentrates on the pro­
ties they face with regard to health, social adjustment
cess ratherthan on the product, we cannot go by simple
and dependence. The book highlights that these issues
cost effect! vity.
become particularly critical for older women. Quite
The First Five Years is as much a labour of love
clearly, gender issues are relevant in analysis of popu­
as a lucid and analytical study of an area that requires
lation ageing as the proportion of elderly females
a more detailed look by the government, private and
increases faster than males in the older age groups.
voluntary sector if we are to see any change in the sce­
The authors review the concept of adequate
nario as it exists today.
social security for the elderly meticulously. Despite
Annie Koshi

INDIA’S ELDERLY: Burden or Challenge? bv
S. IrudayaRajan, U.S. Mishraand P. Sankara Sarma.'
Sage Publications, New Delhi, 1999.

62

THIS book explores the widespread feeling that the
elderly are becoming a burden in Indian society. By
defining India as an ageing nation, the authors caution
us about the implications of an increasing growth rate
of the elderly population, accompanied by a decline in
the growth rate of the general population. They specu­
late that the decreasing rate of mortality may convert
the country into a nation with a greater population of
old, frail and dependent people presenting a burden on
the socio-economic and health infrastructure if adequate
measures are not taken for the well being of older per­
sons. The transition from high to low fertility is expected
to narrow the age structure at its base while broaden­
ing the same at the tip. For instance, by 2021 the growth
rate of the elderly would be one and a half times higher
than the growth rate of the general population.
The book under review studies the demographic
transition and imbalances in the elderly population
across the various states and union territories of India
Ageing

the various provisions and facilities available in the
country, much more is needed to provide equal oppor­
tunity, employment, social security and welfare to all.
Efforts for poverty alleviation and providing financial
security among the old need to be sensitive to both the
rural-urban divide as well as the organized and unorga­
nized sector differentials. The chapter on Policies and
Programmes through adetailed study of numerous pro­
visions like the provident fund, gratuity, life insurance
and pension schemes, exposes the need to improve
operational efficiency for successful implementation.
The overview of the findings of the National
Sample Survey seems somewhat amiss since acouple
of earlier books have already provided a thorough
analysis. The detailed analysis from the ageing survey
earned out by the authors with the collaboration of vari­
ous leading research institutes in India is, however,
welcome. An understanding of the situation of residen­
tial institutions for the elderly in the major states in
Indiaconducted through a mail survey is illuminating,
as are the findings of the survey conducted among the
inhabitants of old age institutions in Kerala and Tamil
Nadu. The perceptions of the elderly gathered through
group discussions throws fresh light on the meaning
of old age, the advantages and disadvantages of
being old, preferred living arrangements, community

L

involvement and the specific needs of elderly persons.
It is significant how pertinent questions of retirement,
re-employment, inequalities in pension and difficulty
in obtaining benefits from social assistance schemes are
to the elderly. The brief case studies, presented in the
form of life histories, reflect different experiences of
ageing which are meaningful for understanding varia­
tions among a cross-section of the elderly. The final chap­
ter questions the conventional definition of the elderly
(60 and above) and calls for a re-examination of the
retirement age along with age dependency ratios.
The book would enlighten policy makers and
researchers on the needs of the elderly, reorienting
onesthinkingtomakethe ‘burden’as a ‘challenge’.

BhavnaPuri

THE FAMILY IN INDIA: Critical Essays by
A.M. Shah. QrientLongman, Delhi, 1998.
A.M Shah s book brings together eight essays pub­
lished earlier. In the first essay he discusses the
terminologies-elementary familyjoint family, house­
hold and extended family, and the ambiguities he
perceives in their conceptualisation by various
sociologists. He makes a distinction between joint
household and joint family. He accepts the legal
conceptualisation ofjoint family, understood as
jointness in property ownership and ritual performance
tfshraddha citing for this purpose Hindu Law and the
Mitaksara. The members of ajoint family on the other
hand can well be residing in separate households. For
the elementary and joint households, he uses the terms
‘simple’and‘complex’.
The functional aspects ofjoint household and
family are also discussed in this essay. In the former,
Shah emphasises kinship composition, while in the lat­
ter, he stresses joint property ownership and ritual par­
ticipation. He points to the sociological gap in the legal
definition ofjoint family which overlooks the ‘house­
hold’ dimension and the pattern of residence, in this
restricted sense that legally even an elementary fam­
ily would be considered Joint'. According to Shah,
joint households are formed with the addition of
extra members in the elementary family, and they can
be patrilineal, matrilineal, or fraternal extended, with
common residence and hearth. The joint family, how­
ever, represents separate households linked by a range
of social, economic, ritual, and ceremonial relation­
ships, governed by kinship positions which cannot be
reduced to mere property relations.

In the next chapter, the author explores the
changes in the household dimension of Indian society.
He refutes the widely held belief that the erstwhile
rural Indian joint family was the norm which underthe
impact of urbanisation disintegrated into the nuclear
family. He reiterates the necessity to distinguish bet­
ween household and family to avoid indiscriminate use
of the latter term, which entails members havingsepa­
rate residences either in terms of simple or smallerjoint
households, but bound by a multitude of relationships.
Further, Shah lays stress on collecting the detailed
composition of households to help delineate their
various types and their frequency. He discusses the
ongoing process of development and factors that lead
to change in size of the household, thereby enabling a
coexistence of simple and complex households at any
point of time. The separation of households does not,
however, sever the multiple familial ties. Contrary- to
the widespread belief that modernisation and industri­
alisation have enforced a nuclear family norm, the size
of the household has been steadily increasing owing
to a stronger influence of Sanskritization and adher­
ence to traditional norms, notwithstanding migration
and a general process in which the dispersed simple
households become complex.
Shah extends this analysis by examining popu­
lar assumptions and media projections that the joint
household is being replaced by the simple, nuclear
household. Through an analysis of census data from
1871 to 1951, he first demonstrates that the joint house­
hold was never the norm. Its incidence was greater
among higher castes and the business class which
constituted a minor proportion of the population. Fur­
ther. it existed more as a textual norm ofjoint propertyownership and ritual participation. Another barrier
was the low life expectancy and semi-nomadic life of
landless people.
The author then argues that while the emphasis
on joint households has declined somewhat for the pro­
fessional class, it has increased in the rural masses, the
urban business class and lower middle class, as well
as among lower castes as a tool for Sanskritization and
status mobility. This caused an increase in the average
sizeof households and acorresponding increase in the
incidence ofjoint households. It is necessary here to
realise the existence of nuclear households in the past
in order to gauge the steadily increasing incidence of
joint households. Shah further states that even in the
urban, westernised, highly educated professional class,
married children tend to stay with their parents and, if
possible, take care of them, thereby still sustaining
SEMINAR 488 - April 2000

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63

■v

64

small yet joint households. Thus, socio-psychologiThe author then moves to the studies on the pre va­
cal, economic, demographic and status-oriented fac­
lence of caste endogamy in Gujarat. Traditionally, since
tors have contributed to a higher incidence of joint
the principle ofcaste endogamy governs all marriages,
households.
the family becomes embedded in caste. The author
In the nextpiece theauthordiscussesthetensions
describes a range of first to fourth order divisions
and conflicts inherent in inter-personal relations, com­
within castes which are themselves endogamous
plex behaviour patterns of members of a traditional
groups; for these he uses the terms sub-caste and
joint household, and how they lead to itsdispersal. This
sub-sub caste. He states that each division/unit is
dispersal is processual and if explicated step by step,
significant for endogamy and the violation of the norm
places the household in varying contexts. The conflict­
at each higher level alongwith the degree of social
ing emotions and heartburn finally lead to the partition
distance determines the severity of punishment. In
of the joint household. The author describes how the
modem, urban society, this situation is changing for
kinship composition of the household, education, an
with an increase in education and age of marriage,
increase in age at marriage, and need to care for the aged
there is an urge to exercise freedom of choice in spouse
dictate the nature of conflicts and the extent to which
selection.
unity is preserved.
In the final essay of the book. Professor Shah
The next two essays titled ‘Inter-household
decries the lack of academic research on the family and
Family Relations’ and ‘Lineage Structure and Change
the restricted views of social workers, lawyers, and
in a Gujarat Village’explore the terms‘household’and
feminists which have affected family policy. He asserts
‘joint family’, distinguishing them from lineage. In the
the fundamental problem of having a uniform policy
first, Shah conducts a systematic enquiry into the rela­
for India in the face ofdi verse ethnic, religious groups.
tionships between family members residing in sepa­
The situations becomes more complex given a wide
rate households. The multi-functional joint family is
range of family units - simple, complex household,
distinguished from the lineage in its legal and scrip­
joint family, extended family, lineage.
tural sense, as a three to four generation group of males
Further, both popular and sociological discourse
with their wives and children who enjoy rights in joint
has promoted a wrong impression that the joint family
property and in the performance of ancestral sh raddha
is disintegrating. The authordemonstrates that the trend
rituals. The patrilineal kinship relations beyond this
is rathertowards a spread ofjoint family relations. The
three or four generation family are understood as
author highlights the contradictions between policies
lineage relations.
concerning the different elements that constitute the
In the next chapter we learn that the lineage
family. On the one hand, responsibility for taking care
span is much longer and requires the study of histori­
of the aged is on the sons; on the other, couples are
cal data and genealogical records in addition to the con­
expected not to consider the birth of a son as manda­
temporary life of the people. The author highlights the
tory in adherence to the two-child norm. The latter
increase in lineage groups within castes, enumerating
also ignores the patrilineal principle governing fam­
as causal factors population growth per generation in
ily and kinship and the equality of status between
patnlines, and the increased interest in genealogical
male and female children, a prerequisite for the norm
records used as tools for social mobility and high sta­
to gain legitimacy. As the proportion of the aged
tus rank. Shah believes that the importance of lineage
increases, the traditional preference for son will per­
as a corporate group has declined among landowners
sist. By making the family responsible, the state has
and the privileged class with the removal of hereditary
furtherstrengthened it.
privileges in rural society and its declining role in poli­
Overall, A.M. Shah recognises the limited effi­
tics. However, it has gained importance in groups who
cacy of state intervention and policy given its formal
have acquired land and other assets and are literate
structure, disharmony between state and central leg­
enough to preserve their genealogical records. Further,
islatures, inadequate application of laws, the ‘tradi­
marriage alliances are regulated according to the line­
tional orientation of the bureaucracy, and so on. He
age affiliations and great significance is attached to the
ends by stressing the need for further rigorous research
lineage groups in ritual occasions, lifecycle events, sta­
on the family, in particular the degree to which grow­
tus differentiation, veneration of lineage deities, and
ing individualism is now influencing family matters.
folkculture. Even in modem India, the lineages as func­
tional groups play an important role within the caste.
MeeraAhmad
Ageing

BiftWi

L

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Comment
Activism and academic angst
SINCE the 1967 annual meeting of the American
Anthropological Association, the issue of ethical
anthropology or action research has been central to
debates within the discipline. In that meeting, several
anthropologists like Kathleen Gough and Gerald
Berreman wanted to pass a resolution condemning the
Vietnam war. while others like Margaret Mead opposed
it. Mead argued famously that political resolutions
were not in the professional interests of anthropolog}’.
The floor, however, was swayed by Michael Hamer
who declared that ‘Genocide is not in the professional
interests of anthropology,’ and the resolution was
passed (Gough 1990: 1705).
Now that proactive social science is no longer
confined to the Left, especially but not only in India,
68

* This article originated in a panel discussion initiated by Majid
Siddiqui on the ‘pro-active and the politically correct’ at the India
International Centre in February. I am grateful to Majid and other
participants in the discussion for their insights.

several people are beginning to rethink their earlier
assumptions on how social science should engage
with practical politics. The ICHR’s recent decision tc
recall two volumes of the Towards Freedom project by
Professors Panikkar and Sarkar, or the move to tailor
textbooks and exam questions to the prejudices of the
party in power are both excellent examples of social
science research being defined in terms of ‘political
correctness’. One of the charges frequently levelled
by the Right in its effort to appropriate the bureau­
cratic posts that supervise and fund research is that
these posts were formerly bastions of the Left, who
used them to push its own version of secular demo­
cratic history. Historical Materialism, according to
our honourable Hindu historians, was then politically
correct and now needs to be corrected politically.
It is worthwhile in this context to remind our­
selves of the legacy of much of this proactive social
science on the Left, broadly defined. My argument here

Ageing

fiOsi

, , ....... —

A

l

is that leftist preoccupations with the political under­
pinnings of their research are qualitatively different
from those of the Right, not because of the soundness
of their ideology per se but because they have gene­
rated new directions and methods in social science
research. I write here from the perspective of my own
discipline - what is regarded as anthropology in the US
or UK and the twinned discipline of sociology/anthropology in India.
As a result of decolonisation and other radical
movements in the ’60s and ’70s, there emerged a great
deal of self questioning in all disciplines, reflected in
journals like the New Left Review, or Economic and
Political Weekly, to name two popular ones. These
concerns led to a variety of theoretical shifts and new
trends in the social sciences. In anthropology, this was
reflected in newly developing fields such as feminist
anthropology, Marxist anthropology which discovered
class in age-sets and non-industrial societies, anthro­
pological political economy which studied the contri­
bution of imperialism in the formation of class,
community and culture, and more recently, political
ecology. Although’conservative economists like
Milton Friedman have been important to the discipli­
nary mainstream of economics, one is hard put to think
of a single right-wing anthropologist who has pushed
the discipline rightwards in a major way, or who has
produced entirely new arenas of study. At best, debates
have taken place overthe symbolic versus material fac­
tors underlying social cohesion, or between so-called
post-modernists and political economists, but much of
this has been within a broadly democratic consensus.
Of course, in the Indian context, the old Indological
work on caste and religion continues, but there are also
plenty ofcountervailing studies.
Apart from the effloresence of fields, political
engagement on the Left has resulted in three broad
directions of research: (z) an increasing focus on the
impact of colonialism in shaping many apparently
sociologically given categories such as caste or tribe.
This was accompanied by an examination of the
‘invention of tradition’ which accompanied national­
ist movements seeking to create ancient traditions
forthemselves; (z’z) the trend towards ‘reflexive anthro­
pology’. By focusing on their own ancestors, anthro­
pologists looked at the complicity of their own
discipline in the invention of traditions, as also at the
way in which the writing of ethnography distanced
and marginalised the ‘other’; (z’zz) the activist approach
going under the names of ‘development anthropology’,
applied anthropology, or ‘action research’.

... ,.

Academic interventions under each of these
headings have been useful in challenging the status
quo, both in real life and in the discipline. They have
produced new and exciting ways of doing research —
the use of history and literary criticism for example,
or multi-sited ethnography instead of the single village,
caste or religion study that dominated anthropology
earlier. Yet, even within this iconoclastic tradition, there
is the danger of new gods being installed, of political
activism coming full circle and boomeranging on its
protagonists. Below, I focus on two such dilemmas: the
role of anthropologists in attacking essentialisms
and invented traditions, and second, the role of social
scientists in development studies. Ultimately, my
argument is that one is brought back to the question of
what counts as good research, or productive research,
given the current standards of the discipline.
A favourite ‘essentialism’ that has long been the
staple of anthropological attack is the notion of tribe.
So long as anthropologists were attacking the notion
of tribe developed by colonial anthropologists, they
could unambiguously describe themselves as politi­
cally correct. For instance, in pointing out that tribes
were not small bounded homogenous units, that they
had no basis in race, that they were involved in diverse
occupations, and had enjoyed political power based on
internal stratification etc., anthropologists were chal­
lenging conceptions that had helped to sustain colo­
nial rule. Pointing to the commonalities between
adivasis and other groups around them could be part
of a legitimate anti-colonial project in the face of
attempts to preserve adivasi areas as legitimate
objects for colonial paternalism.
However, the same kinds of arguments against
the indigeneity of ‘tribal’ or adivasi populations in
India, or against the theory of Aryan conquest, or.
against the idea that adivasi religions in central India
are not sharply distinguished from folk Hinduism,
often seems to support the Hindu fundamentalist
argument which claims adivasis as ‘backward Hindus’.
They also come into conflict with adivasi movements
which have adopted categories of indigeneity as part
of their claims to the land. The claim that adivasis were
first displaced by Aryans is a useful rejoinder when
Hindutva forces attempt to claim some sort of historic
victimisation or displacement. In a world where cat­
egories are created through reference to multiple pub­
lics in multiple contexts, the claim to have a deep
connection to the environment is often a useful politi­
cal tool to employ in the face of obdurate states intent
on preserving their control over resources. In such con-

69

I

SEMINAR 488 - April 2000

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70

texts, anthropological critiques, both of certain catego­
ries like indigenous peoples or certain environmental
movements, are doubly problematic.
In fact, much of the research on marginalised
groups like adivasis or on social movements came
about due to a desire to engage with political action,
and do pro-active research. But in the process, anthro­
pologists or sociologists have often highlighted the
manner in which these groups construct identities,
and the global sources of their self-descriptions, e.g.
in North American environmentalism. As PeterBrosius
has pointed out in a recent discussion in Current
Anthropology (1999), there is a certain irony in the
fact that critiques of essentialism which began as cri­
tiques of structures that perpetuate inequality have
ended up turning against those who are challenging this
inequality. Perhaps there is a need to make a distinc­
tion between the essentialism of the oppressor and
the oppressed.
On the other hand, one might argue that any
essentialism, especially one based on identity, is dan­
gerous, regardless of who is claiming that identity. Cer­
tain categories, especially those involving identity and
exclusion such as ‘indigenous’ lend themselves more
easily to passion. They also enjoy better circulation in
a globalised world where donor lending and military
action have increasingly intervened to defend identi­
ties defined in religious or ethnic terms at the expense
of identities based on other attributes such as class.
In other aspects, however, it is less easy to feel
certain about the correctness of one’s stand. Forexampie, movements like Narmada Bachao Andolan orthe
fishworkers’ movement are often criticised forclaiming that adivasis or fishworkers want to preserve an
environmentally friendly lifestyle, when in fact the
adivasis and fishworkers themselves want all the
attributes of an unsustainable lifestyle. This is pointed
to as evidence of the essentialism of these movements
and their leaders, or at best the use of ‘strategic essen­
tialism' in some political interest (see for example
Baviskar 1997, Gupta, 1999). Yet, there is no corre­
sponding focus on the essentialism of the market, or
on the power of the hegemonic discourse which makes
people reject their earlier lifestyles as backward. If
movement leaders put words into the mouths of their
followers, so do the state and market, and much more
successfully at that, through all the advertising and
official power at their service.
Opposing romantic essentialism or strategic
essentialism to some authentic identity as described
by a social scientist is problematic in that all identities
Ageing

are relational and contingent upon particular dis­
courses and contexts. At. various times people may
want to drink Pepsi and drive around in fast cars, or
watch Madhuri Dixit films on TV, without, however,
wanting to lose out on their ancestral homes or destroy
their traditional fishing grounds. To claim that envi­
ronmentalism is an ideology foisted by activists on
adivasis or fisherpeople because it appeals to interna­
tional audiences ignores the local material context of
this ideology. In his discussion of what fisherfolk hope
to protect when they demand their ‘right to nature’
(Gupta 1999: 2316-7), Gupta assumes that their only
concern is bettering their own livelihoods, which could
be served by everyone being given assistance to acquire
trawlers. However, as Aparna Sundar shows, the
opposition to trawlers fishing in the monsoon is not
because of envy, but because ordinary fishers and no
just their leaders have an ecological understanding of
the sea and its resources: ‘When I suggested that the
solution might be assistance for all fishers to acquire
trawlers, I was told, “And will there be enough fish for
that? The government encourages us to ‘develop', to
buy trawlers. But can we all do so? Can everyone own
a plane or even fly in one”?’ (Sundar 1999: 105-106).
Ofcourse, not every adivasi orfisher isan environmen­
talist. As in every society, there are class differences
among them; some are more aware and articulate or
just plain interested compared to others. Certainly,
however, not all the voicing of environmentalism is due
to outside activists, as the state would like to claim.
Calling something or someone ‘essentialist’ has
become the favoured form of abuse in the social
sciences these days, a superior variant to the older
‘stereotype’. Yet, perhaps, we need to pause in our
wholesale attack on essentialism and examine the con
text in which we make the critique. An argument that
is commonly made is that the anthropologist or socio­
logist has a professional duty to her discipline, which
requires the production of truth, however unpalatable
to the activists with and on whom she has done her
research. This, however, often tends to be a rather
self-serving argument, defining the ‘truth’ as whatever
the anthropologist wants it to be. If one claims to be
writing the truth about a people or a movement, that
writing should be accessible to the people concerned
to present their own version of truth. This is of course
not a simple issue - some like the pseudo-Hindus of
Benaras may refuse to recognise truths about them­
selves in a film like Water - but it is at least worth try­
ing. It is also productive of better research. In many
cases our ‘truth’ is based on short term research, which

. L

The Pakistan-India People’s Solidarity Conference
New Delhi, July 12, 2001
Declaration
I. Preamble:
For over half a century now, the people of India and Pakistan have borne the burden of
hostilities between the two States. We, the representatives of numerous civil society groups,
which have endeavoured for years to reform relations between India and Pakistan, welcome
the Summit between General Pervez Musharraf and Prime Minister Atal Behari Vajpayee and
urge that they seriously engage in a sustained dialogue. The resources of the two countries
must be transferred from bombs to books, from submarines to schools, from missiles to
medicines, from frigates to food, from runways for bombers to railroads for people. The two
leaders must also pledge to eliminate the terrifying nuclear menace that threatens the people of
the entire South Asia region and the whole world.
***

IL The Pakistan-India People’s Solidarity Conference has identified and arrived at an
agreement on three major areas of concern between India and Pakistan, which we feel need to
be addressed by the two Governments. These are as follows:
Nuclear Weapons
The nuclear weapons programmes of India and Pakistan have heightened mutual tensions and
placed the entire South Asian region in grave danger. The two countries must commit
themselves to total nuclear weapons elimination in the world and to the complete
dismantlement and destruction of their own nuclear armaments and associated systems, and
jointly return to the agenda for global disarmament.
Democracy
We affirm that peace, democracy and justice are indivisible. Hostilities between India and
Pakistan have dangerously fuelled religious fundamentalisms and national chauvinisms. The
support extended to these forces by the Indian and Pakistani States seriously undermine
democracy, the rights of working people, marginalised communities, minorities and women,
and threaten intellectual freedom and free speech. We call for Pakistan’s return to
participatory democracy and representative rule based on the principles of non-exclusion of
any section of society, respect for universal human rights and freedom, and speedy
empowerment of the people. We also call for the strengthening of democracy in all parts of
India to attain the same objectives. These acts are crucial for a lasting peace between the two
countries. We call on the two leaders to recognise that today’s needs and tomorrow’s great
possibilities are more important than yesterday’s sad injuries, and that old mindsets need to
change with the times.

Kashmir
The Kashmir issue is not only a territorial dispute between the two States but involves the
people of Jammu and Kashmir (which includes Jammu, Kashmir, Ladakh, Muzzafarabad,
Mirpur, Gilgit, and Baltistan). Therefore, a just and democratic resolution of the Kashmir
dispute demands the involvement of the people on both sides of the LoC in a non-sectarian

solution. A Kashmir solution can work only in the atmosphere of Pakistan-India friendship,
which both Governments must guarantee.
For fifty-four years the Indian and Pakistani States have not only failed to resolve the Kashmir
dispute, but have also been responsible for grave Human Rights violations. The leaders of
India and Pakistan should focus attention on the plight of the widows and half-widows, the
orphans, the bodily wounded, the psychologically traumatised, the socially ostracised, and the
physically uprooted—irrespective of religious, ethnic or political background. Let all sides
reflect upon the tremendous suffering in Jammu and Kashmir caused by the denial of political,
social, economic and human rights by India and Pakistan, and guarantee the implementation of
full democratic and political rights to the people in all these areas.

III. We call on the two governments to:
1. Withdraw all draconian laws in both countries that violate Human Rights.
2. While we welcome all measures such as release of fisherfolk, easing of travel restrictions,

this must be expanded to allow free movement of people between the two countries, and
remove travel and visa restrictions, (including police reporting) through a formal
agreement between the two governments.
3. Withdraw the order for prior Government permission and clearance to hold international

meetings, conferences, seminars and workshops.

4. Lift restrictions on exchange of newspapers, magazines and journals, etc.

5. Normalise cultural and trade relations between the two countries.
6. Cease hostilities with immediate effect in Kashmir, initiate the process of disengagement of

armed forces, and terminate support to armed groups, both State and non-State.

7. Involve the people of both sides of the LoC in finding a democratic, non-sectarian solution
to the Kashmir problem.
8. Rehabilitate all those who have been affected by the war in Kashmir, particularly women,
and create the conditions for the return of all refugees and exiles.
9. Commit to a Nuclear Freeze. This would entail no further nuclear testing, no development,

deployment and induction of nuclear weapons, and no further efforts towards the setting
up of Command and Control systems.

10. Take a principled stand against “missile defence” and for global nuclear restraint measures
such as de-alerting and separation from warheads from missiles.
11. Develop a pacifist, non-militaristic, non-masculinist view of national security, which would
lead to a mutual reduction in the armed forces, and utilise the freed resources for meeting
the people’s social and economic needs. Both governments should also commit themselves
to a time-bound programme for the systematic reduction of military spending, both direct
and indirect.
12. Agree to complete transparency in their CBMs.
13. Cease all acts of subversion, overt or covert as well as hostile propaganda and media
campaign against each other.

14. Demilitarise Siachen Glacier

MESSAGE From H.H. DALAI LAMA

1 am very happy to greet the participants of the Pakistan-India People’s Solidarity
Conference being held in New Delhi on July 12, 2001.
I have lived in India for over 42 years and I have for many years felt very strongly for the
need for understanding and good relations between India and Pakistan. For many obvious
reasons it seems senseless for the two countries not to have good relations. It pains me to
hear and read about the great amount of suspicion and lack of understanding between the
two countries, especially at the governmental level. At the same time I have been greatly
encouraged by the friendly feelings that have been expressed and shared at the peoples’
level, especially in the fields of culture and sports. I was therefore very happy when
Prime Minister Vajpayee visited Pakistan a few years ago. I am now extremely happy
that President Musharraf is soon visiting India at the invitation of the Indian Prime
Minister. I am sure that these summits will go a long way in contributing to building trust
and friendship between the two nations and their peoples.
I have always believed that attempts at various levels should be made in achieving
understanding, trust and friendship between India and Pakistan. And in some cases
private individuals and non-governmental organizations have a greater role to play. In
fact I am quite certain that the contribution from such quarters has to some extent made it
possible for the leadership in India and Pakistan to take the initiative in holding the
forthcoming summit. I would therefore like to express my special appreciation to people
like you who are holding this Pakistan-India People’s Solidarity Conference.
May India and Pakistan see a new chapter of friendship and understanding for the peace
and prosperity of the peoples of the two countries.

With my prayers and good wishes,
(Signed) Tenzin Gyatso
the Dalai Lama

July 11, 2001

Message from Jose Ramos Horta:

As you gather today in the Pakistan-India People's Solidarity Conference
I extend to you all my warmest greetings and wishes of success in this
Important and timely conference.
I have read the draft of your joint declaration and I believe it to be a very
constructive and balanced document that could be easily endorsed and
implemented by peoples and leaders of the region.

Civil society is playing an increasingly important role in shaping policies the
world over and it could have a positive decisive impact on this seemingly
intractable conflict. In this globalised community interconnected by the electronic
media and the internet, foreign policy and the fate of nations can no longer rest solely
in the hands of a small group of diplomats and politicians. You can make a
difference, you can succeed where others have failed.

The peoples of Kashmir, India and Pakistan deserve the peace, tranquility and
prosperity they have dreamed about for decades. Some of the best brains in
the world originate from your region. They have excelled in every field
of human endeavor. So it is natural that their combined intelligence and
common sense will lead to some simple and creative solution.
In solidarity.

Jose Ramos-Horta
Nobel Peace Prize Laureate (East Timor)

Message from Cora Weiss:
Congratulations to every one of you assembled in this extremely important
gathering at this extremely important moment in history. The Hague
Appeal for Peace learned early on that governments will not move until
and unless organized civil society leads the way. The heads of state of
India and Pakistan should thank you. We also learned that no agreement
can be sustained unless both government and civil society are at the
table, with all the players, not just "the sides". Thus women, youth,
the religious sector, diverse civil society bodies that will have to
implement the agreement need to have a stake in creating the agreement.
The South Asian conflict has gone on for far too long, with far too much
waste in life and destruction of land and property. As two of the
players are nuclear powers it has the potential of ending up destroying
life on earth, unless it is contained and resolved.
At the Hague Appeal for Peace conference in May 1999, Indians and
Pakistanis and Kashmiris read each other's poetry, exchanged views for
hours into the night, and demonstrated not just an ability to get aong,
but a passionate desire to live together, side by side in peace.

1 salute you for your constancy, for your dedication to seeing this
unnecessary conflict resolved, for your courage and determination to
help the governments which, like any people in trouble, often need third
parties to show the path to peace.
We support the Agra summit. We support the statement of the Pakistan-India
People's Solidarity Conference. We wish you every success.

With warm wishes,
Cora Weiss, President
Hague Appealfor Peace

Art of Living Foundation

Pakistan-India People’s Solidarity Conference, July 12, 2001

Message from His Holiness Sri Sri Ravi Shankar

Human evolution is to move from limited boundaries to unlimited potential. For
centuries, human race has made progress in the fields of science, technology and
politics, and now it is time to bring back the human values that were somehow ignored
in the past.

We need to remember first and foremost that we are part of one divinity and secondly
that we are part of one human family. Right education is that which unites us in love and
peace and takes us beyond the political, social, racial and religious boundaries.
I wish this conference reaches the people in both the countries and clears the
misgivings by educating the people in our common heritage. I also wish this conference
opens a new chapter in cooperation and brotherhood by reminding us that we need to
live in harmony, enrich our diversity and forget and forgive all the past misgivings.
I congratulate the organizers of this conference for fostering brotherhood and peace in
our continent.

Signed,
Sri Sri Ravi Shankar

Art of Living Foundation
No. 19, 39th ACross, 11th Main, 4th T Block, Jayanagar
Bangalore 560 041
www.artofliving.org

J

List of Participating/endorsing Organisations

Action India, New Delhi

•

Association for Communal Harmony in Asia

Akhil Bharat Rachanatmak Samaj

•

Association of Parents of Disappeared
Persons, Kashmir

•

Association of Peoples of Asia (India)

•

Bank Employees Federation of India

•

Bangalore Platform Against Nuclear
Weaponisation

All India Democratic Women’s Association

•

BEL Employees Union, Bangalore

All India Federation of Trade Unions

•

Bharat Gyan Vigyan Samiti, Bangalore

Akshara, Mumbai
All India Bank Employees Association
All India Central Council of Trade Unions
All India Christian Council

Centre for Education and Documentation.
Bangalore

All India Insurance Employees Association

All India People's Resistance Forum

•

Centre for Dialogue & Reconciliation

All India Peace and Solidarity Organisation
Centre of Indian Trade Unions
All India People’s Science Network

Centre for Social Work and Research. Tripura

All India Progressive Women's Association
•

Centre for Women's Development Studies

•

Centre for Peace & Progress, Kolkata

•

Citizens Against Nuclear Energy, Bangalore

•

Campaign Against Nuclear Weapons,
Kolkata

Alternate Lawyers Forum

•

Champa Foundation, Delhi

Anti-Nuclear Movement, Nagpur

•

Chhattisgarh Anu Mukti Manch, Chattisgarh

Anglo-Indian Guild

•

Citizen’s for Democracy

All India Students Association
All India Students Federation
All India Trade Union Congress

All India Youth Federation

Ankur, New Delhi

Delhi Forum

Anumukti, Vedchhi (Gujarat)

Delhi Science Forum

ASHA, Lucknow

Democratic Teachers Front, Delhi

Association for Advocacy and Legal
Initiatives, Lucknow.

Democratic Youth Federation of India

•

Himachal Vigyan Manch

•

Human Rights Forum. Hyderabad

•

India Centre for Human Rights & Law,
Mumbai

FARR, Kalahandi, Orissa

•

India Peace Centre, Nagpur

Federation of Medical & Sales
Representatives Association of India

•

India-Pakistan Friendship Society

Documentation & DisseminationCentre for
Disarmament Information
Ekta? Mumbai

•

Eklavya. Madhya Pradesh

India-Pakistan Soldiers' Initiative for Peace

•

Federation of Voluntary Organisations for
Rural Development

Indian Council of Trade Unions

Focus on the Global South, Mumbai

Indian Federation of Trade Unions

Forum Against Oppression of Women,
Mumbai

•

Forum for Confederation in the SubContinent, Delhi
•

•

Indian Institute for Peace, Disarmament and
Environemntal Protection, Nagpur
Indian National Social Action Forum

•

Indian Scientists Against Nuclear Weapons,
Bangalore

•

Indian Scientists Against Nuclear Weapons,
Chennai

Forum for Science and Development,
Karnataka
Forum of Scientists, Engineers and
Technologists, West Bengal

Indian Social Institute. Delhi

Forum for Women’s Health, Mumbai
•

Indian Society for Cultural Co-operation &
Friendship, Delhi

•

Initiatives Women & Development, Mumbai

•

International Energy Initiative

•

Institute of Women’s Development, Orissa

•

Jan Natya Manch, Delhi

•

J&K Public Commission on Human Rights.
Srinagar

Global Women's Lib (India)

•

Jagori, New Delhi

•

Greenpeace, India

•

Jan Vigyan Vedica, Andhra Pradesh

•

Harijan Sevak Sangh

•

Jharkhand Organisaiton Against Radiation.
Jaduugora

•

Haryana Cyan Vigyan Samiti

•

Foundation for Integrated Research in
Mental Health. Thimvanantpuram

•

Free Legal Aid Committee, Jamshedppur

Gandhi Peace Centre
•

Gandhi Peace Foundation, Delhi
Gandhi Seva Sansthan. Bihar

•

General Insurance Employees Union

Journalists Against Nuclear Weapons,
Chennai

National Confederation of Officers
Associations of Central PSUs

Kali for Women, New Delhi

National Council of Churches in India.
Nagpur

Kinnaird College Old Students' Association,
(India)
Karnataka State Peace and Solidarity
Organisation

National Federation of Indian Women
Naujawan Bharat Sabha
New Entity for Social Action

Kerala Shastra Sahitya Parishad

Nirantar, New Delhi

Lawyers Collective, New Delhi
Nishant Natya Manch, Delhi

Legal Resource Centre, Palampur, Himachal

North East Network, Assam, Meghalaya.
Left & Democratic Teachers' Forum, Delhi

Oxfam India Trust

Lok Abhiyan, Lucknow
Lok Raj Sanghatan, Delhi

Pakistan-India People's Forum for Peace
and Democracy

Lok Sahet Manch. Punjab

Partners for Law and Development. Delhi

Lokayan. Delhi

Paschimbanga Vigyan Manch. West Bengal

Mahila Samakhya State Office, UP

PEACE, Delhi

Mahila Sarvangin Utkarsh Mandal, Pune

People Tree

Manasa. Bangalore

People’s Rights Organisation, Delhi

Madhya Pradesh Vigyan Sabha

People Union for Civil Liberties, Delhi

Media storm. New Delhi

People Union for Civil Liberties, Jaipur

Movement in India for Nuclear
Disarmament. Delhi/Mumbai

People’s Union for Democratic Rights
Physicians for Peace, Chennai

Movement Against Nuclear Weapons,
Chennai

Pondicherry Science Forum

Muslim Women's Forum

Pravah, New Delhi

Nari Samata Manch. Pune

Public Interest Research Centre, Delhi

Nirantar, Delhi

Raqs Media Collective, New Delhi

Narmada Bachao Ando lan

Revolutionary Youth Association

National Alliance of Peoples Movements

Saheli, Delhi

SAHMAT. Delhi

•

Youth for Unity & Voluntary Action

Sama. Delhi

•

Youth Welfare Association of Haryana

Samvada

Sangini. New Delhi

SOUTH ASIAN & Pak-India groups based
abroad

Sandarsh. Goa
•

Ambedkar Centenary Trust London. UK

Science for Society

Asian South Pacific Bureau of Adult
Education

Shramik Mukti Dal. Maharashtra

Shakti Shalini. Delhi

•

Association for India's Development (AID)

Society for Citizens Concerns, Delhi

•

India Development Service. Chicago.

Stree Sangam. Bombay

INFORM, the Women and Media Collective
and the Movement for Inter-Racial Justice
and Equality, Sri Lanka.

Student Christian Movement, Trivandrum

Nuclear Disarmament Conference. Dhaka.

Students Federation of India

South Asia Peace Coalition.

South Asian Network for Alternate Media

Tamil Nadu Science Forum

•

Coalition for a Egalitarian and Pluralistic
India(CEPI), Los Angeles

Tarshi. New Delhi
Vachan. Nasik, Maharasthra
Vanangana, Banda, UP

Vikas Adhayan Kendra, Mumbai
Visthar. Bangalore
Wan Kamgar Sanghathna, Nagpur

Women's Association for Mobilisation and
Action, Lucknow. UP

Women's Centre. Mumbai
Womens Initiative for Peace in South Asia
Workers Solidarity, Delhi
World Conference on Religion and Peace
Youth for Nuclear Disarmament, Delhi

Pakistanis for Peace and Alternative
Development (PPAD)

S.No __________________ Pakistani Organisations_______________
_1_ National Workers Party (NWP)_________________________________________
_ 2_ Jeaye Sindh Mahaz__________________________________________________

_J3_

Saraiki National Party
____________________________________________
_ 4_ Tehreeki Istiqlal_______
_ 5_ Baluchistan National Movement (B.N.M)__________________________________
_ 6_ Labour Party Pakistan _______________________________________________
7 Baluchistan National Party (BNP)_______________________________________
_l8 Balochistan National Congress (BNC)____________________________________
9 Pakistan Institute of Labour Education and Research (PILER)_________________
10 Railway Mehnatkash Union____________________________________________
11 Railway Inqilabi Union________________________________________________
12 Railway Workers Union_______________________________________________
13 Muttahida Labour Federation___________________________________________
14 Pakistan Trade Union Federation_______________________________________
15 National Trade Union Federation________________________________________
16 All Pakistan Federation of Labour_______________________________________
17 Workers, Employer Bilateral Council of Pakistan (WEBCOP)__________________
18 Human Rights Commission of Pakistan (HRCP)____________________________
19 Anjuman Taraqqipasand Musannifeen___________________________________
20 Progressive Writers Association________________________________________
21 Social Democratic Movement__________________________________________
22 Forum for Peace & Development_______________________________________
23 Idara-e-Aman-o-lnsaf________________________________________________
24 Tehrik-e-Niswan_____________________________________________________
25 Forum for Social Studies______________________________________________
26 Centre for Pakistan Studies (Karachi University)____________________________
27 Catholic Social Services______________________________________________
28 Hamdard institute of Information Technology______________________________
29 The News, Daily_____________________________________________________
30 Centre for Women's Studies___________________________________________
31 Dawn, Daily________________________________________________________
32 Sustainable Development Policy Institute_________________________________
33 Quid-e-Azam Universaty______________________________________________
34 Khaldunia High School, Islamabad.______________________________________
35 Pakistan Medical Association (PMA)_____________________________________
36 International Physicians for Prevention of Nuclear War (Pakistan Chaper) (IPPNW)
37 Pakistan Doctors for Peace and Development (PDPD)_______________________
38 Wokers Educations and Welfare Association Peshawar______________________
39 Baluchistan Institute of Development Sciences and Practices (IDSP)___________
40 Pakistan Women Lawyers Association (PAWLA)___________________________
41 Aurat Foundation_________ __________________________________________
42 Baanh Beli_________________________________________________________
43 Women Action Forum (WAF)___________________________________________
44 Urban Resource Centre (URC)_________________________________________
45 Sungi Development Foundation________________________________________
46 South Asia Partnership - SAP-Pak

The Pakistan-India People’s Solidarity Conference
Signature Campaign for Peace
Page

Name of Organisation/Person:
City/Town/Village/State:

Name
1

2
3

4
5

6
7
8

9
10
11

12
13

14
15

16
17
18

19
20

City/Town/Vill/State

of

pages total

Signature

The

Pakistan-India People’s Solidarity Conference

Look at Us!
Just look at us. We fought side by side for our freedom, and then decided we couldn’t live

together, so we fought and parted. We couldn’t live together and yet we haven’t learned to

live apart as civilised neighbours. More than half a century later we are still fighting. We are

so obsessed with fighting each other and spending all our resources in destroying one another

that nations a tenth of our size are far ahead of us. Ours is perhaps one of the few places left
in the world which still suffers from drought and famine. And the rich nations? They grow
richer on the blood we spill, on the one hand telling us we must behave ourselves and be
friends, and on the other selling weapons we can hardly afford, to kill one another.

Just look at us. Over a billion people in South Asia are affected by the tensions between India

and Pakistan. And yet, we are unable to resolve our differences and get on with life. Our
leaders claim that they speak for all of us when they say they will not sell out the interests of
their people when they talk to the “enemy.” But when was the last time they asked you or me

what we wanted? When was the last time we told them what we wanted?

When the Agra Summit was announced the people of India and Pakistan were hoping against

hope for a breakthrough. In an expression of support for the reconciliation of the two
countries hundreds of people gathered in New Delhi on 12 July, 2001. They were

representatives of over two hundred broad-based civil society organisations and people’s
groups from India and Pakistan— many of whom have been working for peace in the
subcontinent for years— who spoke for thousands of people at the grassroots level. All day

they discussed, debated and even fiercely argued about the various issues that have plagued
both countries, but in the end they achieved what their leaders were unable to achieve— a

Joint Declaration!

This Declaration has also been endorsed by a number of eminent people: two Nobel Peace

Prize Laureates— H.H. Dalai Lama and Jose Ramos Horta of East Timor; Cora Weiss,

President of the Hague Appeal for Peace and the International Peace Bureau, and the spiritual
leader, Sri Sri Ravi Shankar. In fact Jose Ramos Horta, after reading the Draft Declaration

called it" a very constructive and balanced document that could be easily endorsed and

implemented by peoples and leaders of the region."

We believe that these are extraordinary times, which require extraordinary actions. But

instead of seizing the moment, our leaders have allowed the hawks to have their way yet

again. They have disappointed us. But can we afford to sit back and see all the goodwill and
hopes generated by Agra trickle away before our eyes? Can we allow things to slip back to

square one? Is this how we’d like the world to look at us, as people who are unable to resolve
their differences?

Join the Signature Campaign for Peace being launched simultaneously in India
and Pakistan, which will culminate at a Celebration for Peace at the Wagah
Border on the night of 14th /15th August.

Take five minutes to read the Joint Declaration.

Say YES to Peace by signing the form.
And then let’s together say to the world:

Now look at us!

Pakistan-India People’s Solidarity Conference Coordination cell in New Delhi:

Sonia Jabbar (CNDP)
D41 Jungpura Extn.
New Delhi 110014

Email: sjabbar@vsnl.com
Prabir Purkayastha (CNDP)
308 Elite House,
Zamrudpur Commercial Complex
New Delhi 110048
Tel: 6476580.
Email: sagrik@vsnl.com

2

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■

t- i'-:

« y f-i4.-1 .<«.

V...

■b

G]£R-h

'r<-.-!'UCa! ..C.mkJ o| E;?
XV
IEv.-h-.inio.'L^iCa;td'ion 1994

• ' ” c3. No ?
• c'hntf d ■( ( real (i-i'.f- r.

Hii.ViEW ARTIOM"

<1

Verbal Autopsif s for Adult Deaths:
issues in their 1 Sevel
- . Jopment and
Validation! ■
£?z-.5BEL CbANDIIAMOHAH.* GILUAN H MAl?D£,* LAUH/J
ROOdlGUfif? Al'll? RICHARD J HX

ES*

med’calVu'-'^ amassment of cwi.ns oi adult do. ■ >

in sethngs where the p‘ropo\°on cl’peopte who

expensively tc assess causes of childhood deaths The exi-tmo 0.° «
°W- VerDal au,0PS'«s have been us .• j
limited mainly to maternal deaths. This paper aims to hiohhoht thA rri^r006 'n Verbal aijt0PsieL for acful: deaths ■;
0. adult death which need further research
~
'99
e critical issues in verbal autopsies to assess raus •• 3
and discusses issues in 11»
; d thA
?nOf?jeSt,Onna, -......-..........—
ihus, interviewers, responderi ■
in'h*-’'a,idalion c» verbal autopsies, inrhTX ^^2.9JGJe^us mult,P.ie causes of death. - '

^ca)i pc-kc s. procedures for deriving a d.aqno^

™!;dib£i,vert’al^p^^

=fudi®s '’ave varied wtdely. Very few studies of t.»

between offerer t ciruses of dea:i, and between ska es

' h

P°f t?d S0nS!!,vlly and specif.ci’y varied w:d< I ■

■■ '-.-td o^tmre altedtsttve.t mhodsandtOM/uatethe vaf.d.ty c( tl„'XtiX m'

■’Uhc k-.dv cauv .. dHrnbuUan I . Jd Tul
and tn .-.'Mln:- ;nnonv lu^s
i;i,>uniries I:; CXir.ld , (<e(kjem
4
arable lai chudrcn. ’ ;us lack ol
.IAS been seen ar an ;nr..vi.iru dcM ra'aani of
Pv.,:y vacuum on . duh Health that cxL-s withni
•. -A^ernmeius and ^encies.
In K^nun-. -A-Hh poor dao on adult nwrl.tlity vi‘-|
.
repMrsnon
,lr? v..e,|. aild lhl. pf0pv,lio(| o(.
people who me while under medicabcare is low. In such
^•ngs. asceruiuyneut oh causes of death front data
i
,1’"‘ rd:,l^s
^ates of the deceased
Uirt ugh Ktrospe. 11U.ML -stioning in suneysor in demo.
> Mp iK suneil.a...-e stents seems an atti active option •’
;
^hnniue n, known as verbal autopsy (VA;.'nd has
'■sv|.t used to assess causes s childhood deaths . cseral

^'-i'r-ISircc'.. t on.i.in WCir 7|l r t1!, ’

i"T'’S

Me'l'V"“’' Kl,i'rvl Sl'ftL

oac.i

iH

settings.
imupMo ha.c also been use
'1 '-’I a Juh deaths, but almost exciusi .el\
Illis.

the .tssuinj ■ on UkiI
ibost causes oftl.-.ith have distinct symptom .
ipiexes,
and that tlase can be recognized remeniben
and n:ported by |iH icsp. ndents. It also assumes
iat it is
possible to d t ,.|iy deaths, h ISed on the repot

d info.--

matnm. into useful :ateg..st ies cl causes of d ; th The
validity ol v'A is tnlbicnccd by the cause ofdet.’hper >e

and charactet istics of the deceased and bv se . t ,I other
actors, relatmg to the classilkation ,f causes
death
• 'he des.gn and com m of th. queMionmure . td Iteld

procedures. Some o| the key f,ctors and p: .cetscs arc

sumntartzed inl igu ei. fhe de.erminams ot ealidh
shown ,n the I ,glll. are far from complete tn d their
K' i;’° ? Cl’"’Pk"'

ll’e fr! ’ ,e'V0i ,:

The 1methodology
'
of VA ol clrtldhood tie.
icxicv/ed in .in micru;i(io j.d
umk.Sriop in i )
discussed in the com .'.xt of . ........ mimk w
•iduh inurralify in ;
internatijiuiI vvorksli ip in VjxVi

•

--

hs was

iii’.d
' juher

)>ce overleaf). /espiu.1
on the

growmg interest .here is still little i'itfonntpio

213

o <lVhCv<
nntvi -

1 he VA li.’Jaiiquc i*. based on

showm" ’lPS

,

'X''"'

s •
Ite

214

INi< • • XiU'S \LJH. KNALOi i I’llH.M ' H OGX

Prevalence and
wi symptomatology
iof different
,causes of death

• Purpose
|of study
I

''J V

Age & Sox
of deceased

I

___ I

’ > ^Mortality claasif icat-ion]4
e r—Tr-tt.-T.r, „■ /.uzsssassaasBeeasga

- —-i|

,.J

ijpESIGN OF VA TOOLS

r-- —------ -—
Interviewer
* Education
* Age & Sex
* Training

D
A <5
'T
A

------ ►

Type & number of
assessors of VAs
i

T

rj I

iRespondent
!* Proximity
I * Age & sex
I * Education
i * Socioeconomic &
cultural
factors

D
E
R

0

V
I
N
G

Stage of deriv­
ing diagnoses

D

Procedures to
derive diagnoses
from VAa

i
L
E
Q

T

A
(J

T
I
0
IN -

iRecall Periodj—•

i

0
!

!

s
>:

i

Single vs
multiple cad sea
of death

i
(
I
>

VALIDITY OF
VERBAL AUTOPSIES
i

Hucri: I

Dctcrminunts of validity aj verbal autopsies

methodology or validity ofVA for aduh deaths. We have
made a review of alJ the studies that we could find
published up to mid-1993, and that have used VA. We
identified for each study, the country, study period, age
group, main objectives, number of de., ns, approach to
‘The repe rt of the workshop on Verbal Autopsy

,

□is fbi Aduii Deaths
held.il LSHIM II IS.Iaiiu.i.y 1993 is av.iilabh - request.

mortality classification, formal ofquestionnaire, charac­
teristics of interviewer, recall period, type and number of
assessors and the procedures used tc derive diagnosis.
We described and discussed the methodological ap­
proaches applied in these studies in order to identify the
critical issues in the development, use and validation of
VA to determine causes of adult death;.
brief description of the 35 studies which were re-

i

f

I
x

I
(

(

/
VERBAL AUTOPSIES fORADUr: 01 AHIS

Table I

Study

Study

country
01

group

1988 1991

<■ Nepal’
‘anzania'1
. lenya
> apua Neu

05

Age

period

‘ ;uinea*

<5 years

1 he Gambia’

07

he

ambia

io

■< enya11

09

jhana1'

10

Sudan1’’

II

Nepal14

12
13
14

Nepal15
Bciin”

1983 1985
1985 1988
1981 1985

<5 years
<5 years
6 59

1988-1990

<5 years

1982-1983

3 59

1981 1983

<5 years

1989 1991

6 9<>
monih*

1988 1990

9 72
month*
6 60

1989-1990

months
<5 years
<5 years
4 35

1987-1989
NR*
1986 1987

months

15

Ethiopia11

16
17

Bangladesh1’
B; igladesh20

18

Gambia21

19
20

Guinea
Bissau22
Kenya2’

21
22

Philippines24
Lib •ria2’

23

26

Pi pua New
Guinea^
Sc Kgal2’
Bai; •l.idesh'*4
NiHeria''9

27

Vcnienw

2x

Bangladesh'1 n

24

1987-1988
1982-1985
1975-1977
1982-1983
1979-1980

1989-1991

1987
1987-1988

<5 years
>

<5 years

Kenya’4
India”

31
32
33
34

Ba.igudesh'*
Indonesin”
Egyp?7

35

The

Bant adesh”

Ga.noia
' Not reported.

3.V

1987
1984-1985
1982 1983
1980- 1982
1981- 1983
1967-1968
1982- 1983

2101
1 >98

239
173

’he ellkacy of pneumix.\KX'a|
'•Kl-11 ^igarnst acute lover respiratory
tract infections
to equate the impac* of msecucide-

353

treated b<d nets <;n niilana mortality
to evaluate the impjv> of
'■^en'oprophylaxisor-on.numty.bawd

241

treatment l<\- control of malaria
<o evaluate the impact ofcommunity based malaria control riocramme

592

•o evaluate the impus lol Ht.imm

M’l'
mo

89,’

■ iiemmnm on all-cttoe child
.t ty undcause-sjxciik- mortality i

.1
240
358

*05
to evaluate the impact of a primary health

care project on all-cause child mortality
“nd cause-specific mortality

11?
284

to est rblish the relative public health

tmp

• mce of causes ofde?th

492
1349
12 893
184

<6 years
<5 yean

<2 years
ail ages

1982-1985
198.3.1985
1982-1983
1977-1978
NR*
1976 1985

noma

<5 years
<7 yearj

15-44

years,
29
30

to. . tluaie the impact of a community.
pm

1986-1989 1

months

08

No. of

b. '• < intervention for control of

months
06

M;on objectives of study/purpose of

vci nal autopsies

deaths ,

•ndia4

02
03
04

215

,rrMM,upv louls

,,735

No.

<vt

women

to estaoJish iclatixe publx- health
‘mpo - a -,ce of
of dca|h

1-U

«o cst.mate the validity of serbal autopsies to

a^er; c ruses of childhood deaths

303

•o as-sc .s the safety of a community .based

IM

reatment tnal for onch.xrrc iasis control
to assess the relative public health
import -.r.cc-.>f i uuu.s nf jCil(h

jo ;

'‘’measure maternal nuMaliry and to
establish relative
importance of causes of
m.itcrn. ! dvaili'

25

hiK
4 72
2.28
125
542

35
' 34
.58

■ 558
385
•’I
15

216

. INIbHNAHUN M jOURN-il.OI I I' J >■ .'-..IOl:

I AMI I 2

Mi llknh u.cJin

No*

Approach to
mortality
classit'icalion

i>uhh,hi-^ ihu/h J uw/ix »«rimi
luervicv.cr

Format of
q aeMivimalic
Open
Struciurcu

I JU.Uh' •!

R<> .di
pc md

Derivution of
dlii|tnoM*
Assessors
Algorithm

t

two
physicians
two
physicians
interviewer

yes

intervieuer

no

medical

medical
assistant
clinical
officer
nurse

I
week'.
<1
month
I 2
weeks
1-6
week's
NR

NR

yes

NR

lay

NR

NR

no

NR
NR
yes

NR
NR
yes

medical
lay
lay

physician
NR
NR

NR
NR

NR
NR

lay
lay

NR
NR

NR
NR
0-9
months
NR
0 2
months
NR

three
physicians
interviewer
NR
three
physicians
NR
two
physicians
two
physicians
NR

NR
NR
NR

interviewer

no
NR
no

NR
0-3
months
NR
1-16
weeks
1-52
weeks

interviewer
three
phykiciani
NR,
three
physicians
one physician
/computer
three
physicians
interviewer

NRh

ye»

lu>

I 2 years

02

icsti a led
appioach
NR

NR

NR

lay

NR

03

NR

NR

NR

medical

04

NR

NR

yes

medical

05

restricted

NR

yes -

06

approach
NR

NR

d7

NR

01

10
M

NR
re aricted
approach
NR
NR

12

NR

NR

NR

lay

NR

NR

NR

NR

‘■•y ,

NR
NR
NR

NR
no
yea

NR
yes
no

medical
hy
lay

NR
restricted
approach
NR
NR

yes
NR

no
NR

lay
medical

community
health
workers
physician
12 years
community
health
workers
12 years
physician

NR
yes

>«*

yes

Uy
Uy

restricted
approach
restricted
approach
NR

yes

yes

lay

09

14
15
16

17
18

19
20

21

,

NR
NR

university

yes

medical

graduate
physician
assistant
physician

yes

yes

lay

9 years

yes

yes

lay

NR

restricted
epproach
open
ppproach
open
approach

no

yes

lay

NR

yes

yes

lay and
medical
lay

29
30
3<
3?.
33
34

NR
NR
NR
NR
NR
NR

NR
NR
no
no
no
yes

yes
NR
yes
yes
yes
no

lay
lay
lay
Uy
lay
medical

anthropologist/
medical student
community
health
workers
NR
NR
12 years
NR
NR
physician

35

NR

NR

NR

medical

physician

22

23
14

25
26

27

restricted
approach
restricted
approach

no

*

yes

yes

medical

'I

'

.

7 years

NR

1 2

w eck s
2 52
weeks
I 8
weeks
I 44
weeks
NR

0-50
years
NR

NR

NR
NR
NR
NR
2-6
weeks
NR

NR
one
physician

4

ye$
no

yes
NR
no
NR
no

yes

NR

no
no

NR
no

yes
yes

one physician
one physician

interviewer

yes

interviewer

no

one physiciar

no

NR
NR
one physician ’
one physician
one physician
interviewer

NR
NR
no
no
no
no

interviewer

' no

* Serial numbers in Tables 1 am 2 are the same and icier to the same study; reference:, to each smdy are given in Table I.
h Not reported

KI

-a

.1

1
v,LH''A^lJy^

.■

ods" usedPinSthese 'studks ' •A

7

lbe"'cd>-

217 •

Twcnty-one studies have been dmTto^ "’ Ti,blC 2'
childhood deaths ciulit m
d°2 ° SSeSS causcs of
hood death ; a d SIxm
b011’ Udul1 ‘"‘d ^ilda und s,x 10 ass^s maternal deaths.

1n

USkS 01’ VERBAL AUTOPSIFS
Bala obtained from VA can h.* u i .
cause-specific mortality over time tJ -7

categories in VA quesiionnnir
the design ni .

/ J °'Pecd,c disease

r e ,n,N,ca“ons of differences

-Sass- -**-*sa;

>' '[CndS

l‘alSincause-speeificlli;Hlali1vbcUweetS
or to evaluate the effect of inL< und,n‘-rcnigrl,upSi
be used to establish then-1 if-. ' t"Uons- 1 hey can also
of different causes of deathh^n IC|hea,lh ,niPortance

JSSSSSr*. .

(

i» ™“X'?h°r,J""' been ap.

>0 reach a dla ptosis. For example dityorasSeS5ors

acute respiratory infection? 8 and m T™* againS‘
ate the impac of vitamin A supplementin'-

orheninfectio.s aI^. c™5’ ma'aria “"d all
-iH lead to causes of dea Xl’t
caI<:^ries
complexes being grouped toe-th
y.re'ated s.vmP'om
increase the vafidit7o77e
"The " ""
,O
detailed information. Thus'h^tt‘ '7

I

«^d
1

auSe?‘ede''elot«bntof VERBAL
^10111)’Classi/ication

XX^VCAni^,edr,^d 10 dCVC,°P il',d 10 d^
produced and-hln

; •“monalil^'-^-ation

wilh diagnostic algorithms or DrocedSt,°nna togelher
noses) are de< ph/ .
, Proceduresl°derivediag.
Preach. In
lh‘S ,he -^.ricted- ap.
is defined posi^^
•a™ortali<yciassification
from the VA. Fo- the latIer the^A
8n°S"
mined by a lnOrh litv .-I.. ’ r
VA 0,5 arc ,wl detercollection. A spe :'.alL
',riur ^<a

-

~

“S' ? -*2^

studies had used the restricts ** H> L assip|calion, nine
had used the oXpZacL Th^?^'’ a',d 'S,udrestricted approach did no^reporMh'68' ”Ch
‘he
process used todevelon thA

P r hC cr,ler,a and the

use of different apDroachert°rHy C,assifieation The

may affect the vahJity of VA Jnorla,,!?; c,assiiie;nion
‘he design of the Questionnaire on ° °f “u,n,lucnce on

7 °.rca,r ofd-h=d i

Guinea (29 categories) l0S/' P‘1rformcd m Papua New
and the methods, used were the iT"1"1" bacl<grou''d

i-^7^T:i;i^d"’°r,alitycla-ncation
modifications, deally it shouTh" SC“"5gS *'“h n’inor
applicable it ,,1 setth I T
3 COre lhal ^‘"d
' "= changes / : i 8 ;‘^7hOUfdals0acco"’n’nroad-mortality (la sifir’ Spef,nc causcs o'" death. A
of depth which t.emtnortanT S7U[d inCludC 3,1 Caas«
others for which there are we7 IC lea,thprobi<:rr1sand
strategies, and its disease car ■- °gniZCd inlenen^on
Possible, have d -dnet and e- ■
shou,d- as far as
complexes.
as• y recognizable symptom
popTSTShTThT^

I
*

rotate the deTopmem o Tb7T app,ied *°a>d
cation according to the h f
d mortal't.v ciassifiunlikely to be avl able in m Cr"er,a’ H°WCVer' ,his *
d'ceded As an aj TnST nt" S,"Ua,iOn’ Where
from health facilt ies could biXd7Sthe'J^

-nt ofanapprop-iate mortality
■<

.......
different lbnTaTT^Theckli^n
a n",nb%4
withfiherTjuestions or7
^ ^Symp,Orns;chcc®

218

IN I LF NATIONAL. JOURNAL <JI I I IDI M | DLOCi Y

Mgns wnd symptoms, for each of which the interviewer
establishes their presence or absence. A checklist with
filters is u Lst of major symptoms and .igns which, if
present, are followed by a list of related questions or
•modules’. For example, in a ‘cough module’, a positive
response to a niter question on history of cough would
be followed by a module with questions on the duration
and severity of cough, and the type of sputum. A module
can be related not only to a symptom but a.' jo to a specific
category of cause of death, In this case will include
questions on all symptoms’required to dr cnose the dis­
ease category in question. For example, <ugh’ could be
a filter question for entering into a ‘pneumonia module’
which will include questions on cough and also on symptoms such as difficulty in breathing, rapid breathing and
u?*.10 rC?Ch °r
lhc dia»nosis <>f pneumonia;
while cough for > 4 weeks’ could be a filter for entering
into a ‘pulmonary tuberculosis’ (TB) module which will
include questions on symptoms such as haemoptysis
weight loss, fever and difficulty in breathing. Combina­
tions of an open section followed by a ‘closed’ checklist
either with or without filters, can also be used. Of the 35
published studies, three used an open questionnaire, 12
used a structured questionnaire (checklist with or with­
out lilters), seven used a mixed formal and |3 did not
report the format used.
rhe advantages and disadvantages c Topen or slruchared quesuonnatre for health interview surveys have
b«n discussed. • However, the relative merits of the
various formats of VA questionnaire ha.... not been formally assessed. An open fonnat VA questionnaire would
require more skilled, and probably medically trained
ahJ?"1
W°U!d increase inter-interviewer vari­
ability A check list without filters would not require
medicaUy trained interviewers and would reduce interv ewer bias, because interviewers are forced to consider
al symptoms even if they make theirown diagnosis while

dZ
’ VeVer leading
fOrmato* death
may mdCapn '"rcdso
al1
uuails oTIhe
of the symptoms
UKrease the number of symptoms which are falsely rcXI also rot been PreSe?‘' A ChCCkliSt Witl/ nl,ers
vould also not require medically trained interviewers
may be moreefi.cient for data collection, and may mduce
m erv.ewcr b.as. Filters and modules based on a sX.fic
hum”7
Ca'ISe °f death have been used in VA of
ch. dhood deaths where only a few causes of death te^e

studied However this format may be less useful for VA
hkelv to h “ St
the mortali‘y classification is
bke y to have a larger number of category of cause of
death. A potential limitation of this forma' s that a false

sxxr,o ■ r, “'
VA

»1

“''•W "d ..............

t

>'"»■

I he iinpui Jance ot qual'lativc held research into local
concepts of disease and terminology, to facilitate the
process of translation and back-lrunslittion of VA qucsIbnttairei, has been described.40 4J The presence of
several languages and dialects within small populations
will pose problems for the choice of language for VA
questionnaires. In these situations, one could design VA
questionnaires in all the local languages in the study
population or in one major language with an accompa­
nying list of symptoms translated into all other local
languages. Ideally, a model VA questionnaire should be
adaptable for dil lerent sellings by incorporating the local
concepts of disease and phraseology of symptoms.

Inierviewers
Ten of the published studies used medically trained in­
terviewers (seven by physicians and three by medical
assislants/nurses), 24 studies used lay h terviewers and
one used a combination. The educational level of lay
interviewers varied from 7 years of educuion to univer­
sity degree (14 studies did not describe the level of
education ol the lay interviewers). It has been argued that
medically trained interviewers are preferable, but the
re alive merits of the use of lay versus medically trained
interviewers lor VA have not yet been studied. Medically
trained people arc costly. They are more likely than lay
interviewers to interpret the responses to reach a diagno­
sis during the interview and this rniy affect the
repeatability of the diagnosis. If lay inlei viewers are to
be used, a carefully designed, highly struc t ured question­
naire is needed and this has several implications which
are discussed earlier (see above). The preferred age. genand educalion of lay interviewers wil’ vary between
different settings and with the choice of fonnat of VA
questionnaires.

i/'

Respondents
1 he best respondent is obviously the person who knows
the most about the final illness of the deceased. Mothers
are the principal respondents for childhood deaths
foraduTl tl'tiryingKtlle m°Sl aPPr°Pria‘e respondent
fo adult deaths may be difficult because
relationship
be wee,rearers and sick adults is likely to vary in differe.u
tings I or example, a spouse may not be the best
respondent for female deaths and it has been suggested
■nlhecomextofsiudiesofmaternal moruhtythatsislers
arc better respondents than husbands.44 Thus it is im
^-‘■oenquireaboutthepeoplewhocaiedfororX
lived with the deceased during the illness prior to death
as well as about specific relationships to identify the most
appropriate choice of respondent In some cultural set­
tings it nbay not be appropriate to restrict to a single
respondent
b

1
V-*

•

i •

■

,3’

I

I

v«BaLautops|E:

Recall Pl.ric,,

41

* for nDULT deaths

219
“ved at the hnerviX' ly"r7y''int'd?a8nosisd«>ears. Twenty studies did not renor 'T “ 'V‘'S Up 10 50
Period used. The implicatrons ofditr
range O''reci,fl
'Wcnot been studied. It isassun • >""'rCCU" pcriods
ivcek, rs „O1 ,ldvi„5u td l
period exceedrs no empirical evidence for H
A°?d deall,s' bul

deX^'uh

’^^Xtu;:

'hesymptomsf recedingdeath oflckH
may reporl
‘ inn a relative caring for an » . , eh',dmoreaccurately
"•al shorter rcc.ill perio k
kU ’ Th,s wblJ,d suggest
d-liS. Asking rbom ‘ d aX‘
ada'i
may cause distress and so it m u af‘Ci’its occurrence
minimum, as well as a ma^m. ' advisab,e t0 define a
several of the studies review^T
rCCa'1 Per'Od’ as

UiagnoseshavebeenderivedatdifT •
Process and by eWen
?"■"« slagcs in the VA
viewers reached a diagnosi^th assessors- The inter10 Judies (by a physician or L. r
ofin'crview in

a'gonthms is likely to be poor Al h
u?’"5 Wi,hout
‘ 'i,gn°sis<lns stage bv tn -di °“ghderivaii°n ofa
d‘;i:clh«Proportionofde',.)’a ' n’lerv,ewcFs may re" 'i l'l<ely that ||,C icpear,; n. ’’iCf ’f0™111 m'^assified,
l0W ,r,llc gnosis is derived■ whim !' ? B"0‘is Wi'1
nostic 3|gori. „ns for mortalily cla sin g°rithm’- DiaS"
more catego les may be to/cm f d“onswilh20or
during inter c.vs evPn k
implicated to be used
It Would thus .ppear that d medlca,l>' "“‘ned personnel

noses derived without akm 'i
y COmpared >o diagd-agnoscsaec. dingtopredel wdd' Thereforc driving
would be Prefarable for nte " on 78"OS'iCa,gOrdhms
and to
time.
Alfhough II r;„j;|
only one described th.
rithms. The val
cpnimon cause ■
cussed/3, Howp

s"diesx^urfaigori!h-

.vary between dilTerent seuk.'0,:a\cl!nieal expertise may
a|c for Internationa; cmX^ ™r°lbeapprb^

■

al’° varied in (he
XV
fr01” V*
defined diagnostic algorithms in 1 aC,C.Ord,n« 1° preassessor in five, by a pane^li
d'eS
a single .
computer in one and the 0^”^°“ in four’ bV a
reported in one); b- assessoV^08 assessors was not
s‘udies (by a single asXsXin
al8°ri,hm^ in D

assessors in five); while nn
and by a panel of
reported in seven studies. PrOCCdufe tor derivation was

l^ed o/the VuraVV'sXcHty5X'lVril,:‘i»
»»

diognos^ Fo?

Positive history of h.lhX^aVl"1^111
a
neck, convulsions h j uncon^ouX^'m0"’'1'"8, stilT
ofun algorithm w.lj increase a H ?5' rile spccificity
decrease as the nnmkdnd the sensitivity
' Wj||
included in the algorit/ °f Syinpl°ms and .
J conditions
.•* can be
symptoms.
- -inival ex-

of interview

•:

fro™ text book descriptions X n g?rilbn’s defined
some settings due to diflercnccV-r
approPna* *n
of symptoms and sign* of j; ' * ’ cuj!ural Perceptions
combination of
l^ly that a
eyelop a first <.Hfl of di.lgn
lhc
way to
could then be rel d by fiel/tests 3 gOnlhfns’ wh«ch

mediate and asso. i41cd cau^'and'0 UndeflyinJI- Im; O'^ary causes, 1; complex anil h d lnl°r Penury and
‘emis are always used
.
not clear that these
guidi between an tmdcrly ing 'f/id h rhc ubl,ily todistin°" VA in/brmation is dcX T :,,nCd,,,,e^
secondary cause o'’ kath may
“ dan«er ,bat a
msistence on a single cans"
"'“""'^und
option which would keep the nrrIv^ ’’r3" 8,lri,c'ive
Simple. However, pnormg m.1 ? “ Prescnlalion
c°u d lead to misleading resul s n
Of dealh
mulnple causes of. .ath lu tt
*ay “bundling
combination ofcau esasa
belO,rc‘" a common
’•'Ving AIDS/TB ■.•: a sen-.rai80?
°'Vn riefll<e 8^SorTB)andlotrkeXn 0
fro'” ci'her

and presentation of dan A it

r
r

I
I-£ .

i

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{

.toun,,nthcanalysis

1

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IN I I RNAHONAI lOURNAl (»l I-I’ll >1 Ml' »l < >GY

contributes or.ee to the AIDS category mal once to the
1 B category. The presence of multiple .auscs of death
will have an impact on the cstiinulec ositiviiy and
specificity of V A diagnoses.

ISSULS IN VALIDATION OF VERLA
AUTOPSIES
The reported validity of VA for childhood deaths varied
considerably between studies7^23 and the sensitivity
and specificity of VA varied between different causes of
death. For example, in Kenya23 the sensitivity was 89%
and specificity was 96% for malnutrition and 28% and
91% respectively for acute respiratory infections (ARI).
Furthermore, the sensitivity and specificity for the same
cause of death varied between different settings and
tools. Forexample, in Philippines24 the seiisith
I V/\
for ARI was 41-86% and the specificity was
^3%
depending on the diagnostic algorithms. These estimates
of validity of VA for ARI are quite different from those
reported from Kenya. There is virtually no information on the validity of VA
for adult deaths. There has been only one small valida­
tion study of 10 deaths in Liberia.23 It is likely that the
validity w ill vary in different settings, and so tools should
be tested in several settings before being used to assess
cause’-specific mortality rates.46

Reference Diagnosis
In order to assess the validity of diagnoses derived from
a VA it is necessary to compare them \..th a reference
diagnosis. Validation studies will thus involve identifying
(Jeatlis whose causes have been diagnos.d
by the
„
—J refcrtnce j------J
procedure,,and
subsequently subjecting them to
veiba! autopsy. Ideally the reference diagnoses for validation studies should be accurate and reliable, and the
dcaths studied should
deaths
sbpuld be representative of the distribu
distribu-­
tion of causes of death !•-* the community. 1 he following
three options could be considered for reference diagno­
sis: (i) diagnosis reached by clinical necropsy; (ii)
diagnosis of deaths in the community; (iii) hospital
diagnosis.
;i \ ;■ \ ;
Diagnosis by necropsy may be accurate, but would be
very diihculi to achieve in many place s where'only a
small proportion of deaths go to necropsy, and where
necropsy is nol culturally accepted. Th-/may result in a
strong selection bias as the deaths that go for necropsv
tend to be atypical.
H ’
The choice of diagnosis of all deaths occurring in a
community as reference would be less susceptible to
■selection btas. However, since only a sm;; 1 proportion of
deaths in the community are likely to be seen by a
physician, tn places where VA are needed, this is not a
realistic option.

Choice ol hospital diagnosis as rcfircncc may also
introduce sclc.tion bias due to selective access, differen­
tial treaiiniiit success and the socioeconomic
characteristics ol those who use hospitals. The standard
of hospital diagnosis depends on several factors such as
the tt.iming and experience of physicians, local diagnos­
tic preferences and availability of diagnostic facilities.
Snow e( al. have illustrated some of the inherent biases
of the hospital-based approach to validate VA.23,4 Ncverlheksstho.se studies7-3 23 which have tested the validity
of VA using hospital diagnosis as reference have been
valuable in ill aminating the limitations of VA for child­
hood deaths.

i

Sample Size
Ideally the sample size for a study to validate a VA tool
should be estimated to give a sufficient number of deaths
,due to the rarest cause of interest to provide an accept, able confidence interval around the estimated validity of
the \ A for that cause. If the desired confidence limits are
+/—10% for j sensitivity of 80% lor a diagnosis, then
approximately 100 deaths due to the given cause are
required. 1 hus il the expected proportion of the total
deaths due to that cause is 10% then 1000 deaths are
required oveiall. The specificity will generally be esti­
mated more precisely than the sensitivity, but will also
vary with the proportional mortality of the cause in
question.
1 his shows that very large sample sizes are required
to obtain precise estimates of validity if there are many
categories ol cause ol death. Nevertheless, misclassifica­
tion of a cause of death into a closely related ‘similar'
category is of less concern than into a very different
category. For example, misclassification of congestive
cardiac failure (CCF) as myocardial infarction is of less
concern than CCF as pulmonary TB. Thus, related cat­
egories of cause of death could be collapsed into broader
categories to estimate the validity of VA . .-ven if separate
diagnoses were derived initially. It may be of value to
study the validity of VA for many categc-ries of cause of
death, accepting wide confidence intervals for some of
them.
CONCLUSION
Verbal autop hes have been widely used for childhood
deaths, but adequate appraisal of their validity has not
always been addressed. The marked variations and impiecise repoiling of the procedures applied in the
reported studies have made comparisons of results from
these studies difficult. Furthermore, it cannot be as­
sumed that methods appropriate for childhood deaths
are necessarily applicable for adult deaths.
A considerable amount of methodological work

s.

i

I
I

i

VbRBALAU1OP

^ins ioradui. 1 ^CAIHS
'oobtainX'uTa^d'XparaHed ’G" “ "iuCr SCale
on a wider scab
10 Greenwood B M. Gn

'r

F
F
J i

c. .

ii

i son
care programme in the Gambia I
'Ioh“' , pnn,a'T health
Spencer H C. K aseje D C. Mosley W u F"" ' ’88;
> '21 .27.
Rnhert, M. Impact on morul“y ,X~t* £ K' "““S A ' •

-oc-'r*-™"™""...

^XkaUe^iaX'’hl'n,'n'f'><’n

Gha„a. tl

icme has embarked on a proi^ io" I
Tropica' Me‘lverbal autopsy tools to
J * dcvelop and validate
Uifee countries in sub-SaharanTr ’ °Ladult dealhs
lo answer SOm< of the ntethodok^X
S‘Udy ai,ns
*n this review.
o*ogical questions raised

A !“ppl™"---14

W«’KPJr.Pokh.dRp v , ,
A in reducing

PreschooKhiM

acknowlfdgemhn^
16

seas Deveiopmer
OavidRossfnd.hel
S
D UK/ Wc
Or
^opsyworkshopheldin th^^ JP‘ ntS°ribc't‘l^> verbal
and Tropical Medicine in January wj fh0?' °f Hygle,,e
"W to this rcvjew, Wc "“'^'."^^rX'eirvalunble
felicity cut(s and thc mem^ uls°
<o thank Dr
crest group at London School of
Ve'bal 'll'toPs>’
“1 Medicine.
01 of Hygiene and Tropi-

Mallip, M A. Thell^iu,ofAd^,

’ a

’ H.ye,« M d: O’ford u"i'-!ity Pr«
"VH R. Merten,T. Lockett G rFT

I

SrlrC''‘l

Vdem: n/ t

r i»u
mortality u/;
a rural
uc" Ar"“" ..............
474-79.
Shaniebo I'
project
Pi ik. ur 1991; 17:25a 61
'
19
Spika ) S, Munshi M J ‘

21

. ppJ ’-2
Pope.

J
........ .
°r'hc ""der fives. J T,^

■

I*
.......

' ara Car,> childhood i.i d Ul.|i
fW.hon. An..
^r

^l,jU“’P,y >‘le,huj3 'O
V

r

..... .

- “FX.'-'X

'-"XT"---

• V,

ar A "p w

«d loW chMh.^° orXl“™ “ Pneumonia mortality

■

^^,.992;

‘enJ ,nt'rv 'cu* ;... ascertain JlexJud

V*’’<U‘io‘l* <»rPOMmor.

24

.4

B°"C"g J' Ta>lor « R

E:"

P5y"Ur"'gad"’-"^S<X

i

Application of rhe wb ,uXU,>l

uf—-

• Mt-n,:;
“"dertlv'e

'n 'd,ll')'e"

ri,nz‘Verbal au.opry .R O. Ot.^ttu T

""in'

.

Pneumococcal vaccine pXu’dea'th f C' G™"'" 'Sm"h D-

<- “"'“c,'"l'’«er-re>plr„.

n"n ‘"‘'‘<,C"-

‘X^XXnXX^t,
1991; 337: l^X
°f Ga'^ia
M

«/. The efTcei of
n children

26

..

■’XU«. Ch‘,d,’0odd“^n

2!

’ AkJ’pTh

«^^-d

pP *^d«h b, /

1980.9:25 „
GreenuixxJ B M < .
'amnated. ru. t| WCSI
1987; 7: ylw '

Bdtimore:The

“ry lrxa Infection. ln r,„u. N

R ° r;

M Q

Sch
•n Hdnjelade’h. Ann
emong
childm^in^X'
1
^
p
^''
ni
o
|
'>g
!
'
ndrau« ofdeath
.........
........
M

’y C J L;

^0". Heelth a„d NUlrili0„"

X Xkjj ;■

• -ng children in <\

17

« Dmi0l,htK cou„lrirt. 'A X"h“^o' C““"

I
c

"Or,hern

’’Herrem mX^Pm "■'

„

I
?!

22l»

MoXc^ 31:58 91

*v ir j □t CJurncr P A i
^eu Of Mad.mg |.„n
Al^r’ M P. Moftality ;„ , ru
f«.-«w„/iWiS
1
1 N'" Go,jr
tM
Gareh„eM.,.onlainCi
'
.
■'"'”'/nr./,„.I/y„........ ,w;m“A s-';'F'''Gju',-’”/*™rtu.-/ng(,

onc“"'l>ula|!vcs„ Jiesofmortalnv

I "-Hi lor rhe Sure. ntR s,uU.

" ••in.ieM"r^»'■ comparative studies orm„r,a

|

■’'’'<»«/. Seminar

lnlet:,„(ltl„.|

t.x.... . ,h*

Pf

Z'{'F ^WerA. Seminar

aPproachcs io
Umonr,„,hcSvklltjl,cSiu?
->.» 1986. Ir.iernational
. 'moires. Unisers,ty nf Siena. Sien.'juJj’’"
"* !",1"ulf of

p
I

212

INTI K .A ll(»s,''» AlURNAi 0i t.l‘i(»|.xil<H

Bradley A K. Giltei H M. Malum!.uh; endemic
rev.. .ch
project,XXI poinicu lu-duscjul dc.iihin lhe M ihimladii .nr,».
northern Nigeria. 4/i/< Kruft MeJ PuMitol l9h4,7K: J<»$ 71.
.M Mynlli C. Said A A. Aqlun U, AI«Rubu>h S. Uiing puM nuHtcin
interviews at *ne community level, an example from Yemen.
Jiealih Pitltej Planning 1991; h; 282- 86.
Ji Fauveau V. Wojtyniak B, K xnig M A. Chakruborty J. Chcwdhury
A I t.pkiemiology and cuuM uf deulh* <i. iuny *■ men in mud
Bangladesh lut J Epidetniul |9H9, 18: I Vh-15.
,J Fauveuu V, KocniuM A, Cbukruburly J, Chund.iury A I. Ciiuves of
maternal mortality in rural Bangladesh. 1976 85. bull W orld
Health Organ 1988. 66: 645-51.
,J Fauveau A, Blanchet T. Deaths from injuries and induced abortion
among rural Bangladeshi women. Sac Sei AA J 1989; 29: 112127.
Bocrma J T. Mali J K G. Identifying materna mortality through
networking: results from coastal Kenya. Stud Fum Plu/m 1989,
20: 245-53.
,} Bhatia ) C. Maternal Mortality in Anantapur Di\triit. India: Prelimi­

M

I

nary Finding* of a Study. FHE/FMM/85.9.16. WHO 1985.
Khan A R, Jahan F A, Begum S F. Maternal moilulity in rural
Bangladesh: the Jamalour District. Stud Fam Plaint 1986; 17s
7-l2.
57 Fortney .1 A. Susanti I. Gadalla S, Saleh S, Rogers S M, Potts M.

Reproductive mortality intwodcvelopingceua'ri-rs. .bn J Public
Health 1986: 76: 134-30.
?«
Chen L C. Gcsche M C, Ahmed S. Chowdhury . 1, Mosley W H.
Maternal mortality in rural Bangladesh. S-ud Fam Plann 1974;
5: 334-41

Gieqiv o< J A Ni. Greenwood B M. Bradley A K el al A prospc -tivc
s nvey m the o.ukome ol pregnancy in .< rural area ul the
Gambia Hull World Health O'gan 1987,65- 635 43.
«> Rmt \) A. Vaughan J P. Health interview •u/veys in developing
countries a methodological review. Stud Fam Plann 1986; 17:
78 94.
41
Kroeger A. Health interview surveys in developing countries: a review
ol tiiciho li and rcsuliv Im J F/ddemtol 1983; 12) 465 HI.
Bang A I, Bang R A. and the Si: ARCH leum. Diagnosis of causes of
childhood deaths in developing cuuntriei by verbal autopsy;
suggested criteria. Uull World Health Organ 1992; 70: 499-507.
Snow It, Marsh K How uscfi'l are verbal autopsies to estimate
childhood causes of death? Health Policy Planning 1992; 7:
22-29.
44
Graham W, Brass W,_ Snow R W. Indirect Estimation of Maternal
Mortality The Sisterhuod Method. CPS Research Paper 88-1.
1988 London: Centre lor Population Stuoics. London School
ol Hygiene and Tropical Medicine.
4 Gray H R, 1'crhal Autopsy: Using Interviews to t.ieicrmine Causes uj
Death tn Children. Baltimore: The Johns Hopkins University
School ol I lygiene and Public I leullh, Insli'ute for Inter national
Piogtams. Occasional Paper No 14, 1991.
44 Ross D A Mom luring Causes-Specijic biJan land Child Mortality Rates
in Areas Where Death Certijiculion
stems are Weak.
WHO/E$M/UNICEF/CONS/WP/2,1992 WHO.

rT

V'

l

( Revised version received November 1993 J

!

■

> »*mbwb< . .............................. ■ «

i

!

JL

Intornati >nal Journal of Epldemlolooy

1

C International Epidemiological Association 1994

vol. aS. No ?
Printed in Groat Britain

Lottors to the Editor

4
U-

Study of the Disease-H
ealth Seeking-Death Process: Another Use
of the Verbal Autopsy
KhSc0AGFr?RRE2’ K0RTENS|A REYES, HOMERC- MARTINEZ, PATRICIA TOME AND
Sir - Oser the past io years, the verbal autopsy (VAI

ofS:!^‘hnemo,hcr'sciin^

^scs <>" 2, £ ^a«X ™Eh "J,“ ix
I

-“-■existe.ttJ ’TheYAconsists^^*^

■ initSir'^tSsof^’ ,!'c

h«'>h authorities

■"“'’^ein^aPthTXary'Zh^

government and private p tysicianscan receive in 2 ^'

. P ys uans receive points towards their curriculum
(continual medical education) a«- whi A
"C
ur experience began with work at a state-wide level

unpact i i hese training c curses.

Health'' ?w8

‘he Ministry of

SUCteSSr''1

extenL
'nl,'rCSI
,hc use of 'he VA. Ami ha
'■ • s use to the .whole country, with special1
emphases m those states where ARI and a r>
.
rates are particuiarly high. The purpos

I

II

|
I

sx

” =“«xAcute respiratory
infection
(n -98)

i

—ssSHS

I 6 lilonlhi ui ugc (%)
Died at home (%}
Received medical care
prior to dying»%/
Incorrect medical
treatment (%)
Late rcferr.i| to the
hospital ("v)

Acute
diarrhoea.
(n« 34}

71.4

67.6
5S.9

!>).2
81.7

94 |

o53

42.fr

14 7

427

1

i»rii—i.iao t MiJm^wwnswvih* rw .'rv • ,.■-.
’**•«!!*■ ••’af-'’.” ••■■■'■'•'•

j!

IM I <N \■ '

SAI /< >1 IHSAI. Of I 1'11)1 ;M.‘« •!

rd
Hi;ddiserma. i isiilulions in 11
ountry.
lt.b’ committee gives iceomincuduiiuns to .'.•coionnmhers. who in turn choose the best strai

<
lU-ll-IU.NCES

R M‘-h G. n.n^ I /'••• < ”• >"
7°
. ............ I
IntelimuoimI '.’ivgrainv BaHi-.nerv: ‘ehiu Hopklfu UnivcrMy

1

fo'4 .’V..

la summmy, v.c have used the VA as ;u’ inldlacc
between epidemiology and dh.io jraphy, and c. >ve found
,t to be a useful epidemiological tool to ui. serstand
•J-.c process of health-seeking behaviours, both from
n-.other’s and ohysician’s point of view. By using VA at
a st He-wide level* we have discovered areas where appropi n ic interventions may lower mortality rate Based on
results, v.c have planned a.td implemen t’ analionv. i 1; programmv to improv: et sc manager h a of ARI
a.ad '<D in pi 'mcry health care facilities and ■ the home
T.d We plan to evaluate th.* impact of this i erven'ion
through continued use of V?

X coi-

-

sim
stui

■

((XcxMoib I I’-'l < r >•’»■ I’’’■ Snuw H. NUr.” K ’I” '
•“< 't‘i,’•,, ’uH.i.MCs to . vnnatc ch>.dh<MKl cause! ofdvulh? ileul:h I'vluy Humbix 19V 7: X2- 29.
’ Snow R. Annina J. Foster M vr al. Childhood death: Alrica. uso
and limitations uf verbal autopsies. Lam et 1992. .151:3-54.
4 Reyes H. Tomi P Gulscafri II. Mutincz H. Romero C Gutierrez G.
Autops.a 'erba. er. ninvs cvn infeccton respira’cria y diarrea
aguda. Analisis del provesb enkrmedad-ateneb’ -mucrlc. Bui

(im
or

ma
ba*

coi

mi
n=
up
(C
Ol
30
_(
on
on
on

Med Hasp Infant Mex 1993; 50:7-16
5 Interim Programme report W9U. I'ru.oammefor Cuntr I //Diarrhoeal
Diseases Geneva: World Health Organization, document No
Wl 10/CD D/91.36), 1990
6 Cart' Mananeiwnt oj 4( lH<• Respnaiury Injection in Cl A renfur Dcvelopinn Countnct. Manual lor doctors and other senior health
workers (Acute respirators infections control programme). Geiieva: World Health Organization. 1989.

lai

P<

Exact Confidence Interval of the SMR Based on Prevalence
Data
II

F rorn JAMES Ltc

Sn - The si a’• dur J i/.vd morbidity ratio [ AIR), compuled by indirect stan Jardization, compares the
morbidny experience of the ‘exposed* sul j f. is with that
of t/ie ’standard population’ allowing for adjustment of
: onfov.nding. The SMR T. simply the rt t o of O to E,
v. hcie () is the observed number of moi be events in the
•xposed group rvid E is ti e expected number of morbid
ex cuts in the expoised group if the risk of the morbid event
j- the exposed gi oup coir (ides with that of the standard
popjln’ivn?”
Custcmarily.thccomp’Italian of the c.: i.idenceinter.Cl) ol SMR rests on tv.o assuri ions: E has
.'/gligible sm.. pc ng error and Obari. lorn Poisson
-triable. Some writers further assume m ; the prop
:.. .n of the mcib <i event is small so lha' -• variance v.
O i* i.pproxir mtely O aim that its sampib g dhtribui on
i> iiprrbx’nlately Gaussiw. u Other wri ers do not imp. sc these assumptions
ll’.ut the Cl i.l SMR is based
on the c.c.ict Pcisson distribution?"5 I! J’.vcvcr, none of
ife
i.bucks 1 have perused noted that the Poisson
Jiv.Mn; 1 ion is only valid I or in . idence d.u.a bi-crued from
•a cahorl study but not fir prevalence da.a horn a crossof Biu.iitisUvS and Health ’r l\un.;.iks. T natinienl of C s njnuniis. Otcupaiicnijl and Family Medicine, N.t nal i.’i.ivciMiy cl
Suigujxic, NuH. Lov-ei Ken’ Ricgc Load. Sing.r e Vf41.

F.

TaMLB I 9.'' > cunJuk tH f mh r\a!el SMR h>r
lulubaM-Jen the
binomial raisn.n J/i t (/du ddn ihMnbutu»n.i o) O x1” '• 10
SMR « 2, but kj i i ijercnl uirnplc ii:e I n) and proper tun (pl
Poisson

s

Gaussian

O

n

P .

Binomial

20
20
20
20

2000
200
100
50

0.01
0.10
0 20
0.40

(1.22-3.08) (122- • W) (1.12-2.88)
(1 24-3.00) (1.22-’09) (1.12-2 8$)
(1.27-2.92) (1.22 3 09) (1.12-2.83)
(I 32 2.74) (1.22 • 09) (1.12-2.88)

sectional study. Yet the SMR is often esti i ated based on
prevalence data, for example, to compai he prevalence
of hypertension in a group of heavy sn ckers (exposed
gioup) with the age-specific hypertension Tates’ in the
general population (standard populate n). Since the
prevalence ‘rate’ (actually the prevalence rate should be
called a proportion) in the exposed grouo s clearly bino­
mial and nut Poisson, the Cl of O shot ’ I be computed
based on the binomial distribution and >1 on,the Poisson distribulion or the Gaussian approx lation The use
ol Poiiyon isoltcn jusiil'icd by the lad ll . as sample size
(n) increases towards infinity and the pi portion ol subjeds wim moi bid eveni (p) ar proaches ro, and that np
remains unchanged, the binomial 4 slribulion appro.iches the Poisson distribution. N > idheless, these

o
b
Fi

11
g
P
V

I.

a
r
e
I
(
I

J

I

154

SCREENING IN AL

4EN

Tunstall-Pedoe H. 'Who is for cholesterol testing?' Br Med J 1989,
298:1593-4.
Tunstall-Pedoe, H., Smith, W. C. S. andTavendale, R. 'How-oftenthat-high graphs of serum cholesterol’. Lancet 1989, ii:540-2.
US Preventive Services Task Force. Guide to Clinical Preventive
Services. As Assessment of the Effectiveness of 169 Interventions.
Baltimore, Maryland: William and Wilkins, 1989.
Veterans Administration Cooperative Study Group. Effects of
treatment on morbidity in hypertension. I. 'Results in patients
with diastolic pressures averaging 115 through 129mmHg’.
JAMA1967, 202:1028-34.
Waine, Colin. 'Everyone’s Business—Everyone’s Responsibility.'
J Roy Coll Gen Practit 1989, 39:395-10.
Walker, M. and Shaper, A. G. 'Understanding corona y heart
disease: screening and prevention'. Practice Nurse, February
1990, 404-6.
Waller, J. and Morgan, M. A. Review and Analysis of Health
Promotion and Health Education for Chronic Disease. Report
prepared for the United Health Organisation. Department of
Community Medicine, United Medical and Dental Schools of
Guy’s and St Thomas's Hospital London, 1987.
Waller, Jane and Morgan, Myfanwy. The Use of Preventative
Measures in Primary Care. Report prepared for the World Health
Organisation, 1988.
Waller, J. and Morgan, M. Prevention of arterial disease in general
practice. Report from General Practice No. 19. London: Royal
College of General Practitioners, 1981.
WHO European Collaborative Group. 'European Collaboative
Trial of Multifactional Prevention of Cononary Hearth Disease.
Final Report of the six year results'. Lance/ 1986, i:896—00.
Wilson, J. M. G. 'Multiple screening’. Lancet 1963, ii:51-4.
Winawer, S. J. AND Miller, D. 'Screening for Colorectal Cancer’.
Bull Who 1987, 65:195-211.
Zung, W., Magill, M., Moore, J. and George, D. ’Recognition and
treatment of depression in a family medicine practice'. J Clin
Psychialr 1983, 44:3-6.

SCREENING IN
ADULT WOMEN
As in most cases the woman is still the
linchpin of the family, it is obviously worth
making sure that she is as healthy as
possible so that she is up to meeting the
demands made upon her.
(COOK, 1987)
■

INTRODUCTION
WOMEN IN GENERAL THROUGHOUT THEIR LIVES HAVE

more frequent contact with the health care services
than men, particularly at the level of primary care.
They consult not always on their own behalf but at
certain periods acting as custodians of the health of
their babies and children and the whole family. Rightly
or wrongly, it is also still to a large extent women who
take major responsibility for such matters as family
planning. The opportunities for contact with health
professionals in adult women are summarised in Table
17.
The main causes of death in women in adulthood, in
the two age-groups discussed for men in Chapter 5—

L

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Table 17. Opportunities for health service contact in adult
women
LOCATION

General practice
Hospital

Community
Work

TYPE OF HEALTH PROFESSIONAL

GP, health visitor, practice nurse
Specialist medical or
paramedical hospital staff as appropriate
Dentist, chiropodist, family planning clinic,
well-woman clinic, optometrist, pharmacist
Occupational health physician, company
doctor
155

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SCREENING IN ADULT Vv

INTRODUCTION

MEN

25-44 years and 44-64 years—are shown in Table 18.
The main differences between the sexes are worth
noting. In the younger age group, the percentage of

Table 18. Main causes of death in adult women
(England and Wales 1986)

!

CAUSE

% TOTAL DEATHS

NUMBER

Young adulthood
(25-44 years)
Malignant diseases
2585
External causes
Motor vehicle accidents
216
Suicide
297
Others
437
Circulatory disease
IHD
249
Others
532
Diseases of the nervous system
including mental disorders
308
Respiratory disease
202
Other causes
654

47-2
950
781

■!

!‘

I

6439
889
2482
911

2838
4658
2600
6569
2140
5020
34546

17-3

4-6
9-7

14-3

5-6
3-7
11-9
100

5480
Middle age
(45-64 years)
Circulatory disease
Ischaemic heart disease
Other heart disease
Cerebrovascular disease
Others
Malignant disease
Trachea, bronchus, lung
Breast
Alimentary tract
Others
Respiratory disease
(including bronchitis)
Other causes

3-9
5-4
8.0

10721

16665

18-6
2-6
7-2
2-6

31-0

8-2
13-5
7-5
19-0
6-2

48-2

14-5
99-9

I

157

women dying from external causes including motor
vehicle accidents and suicide is half that in men, and
the percentage of those dying from circulatory and
heart disease is very much lower. For nervous and
mental disorders, respiratory disease and other causes,
men and women are about the same. But women have
double the chance of dying from malignant diseases as
their male counterparts. In the 45-64 year age group,
women begin to catch up in relation to death from heart
disease but remain decisively in the lead in death from
malignant disease.
In this chapter we will look in detail at the current
screening programmes for cancer of the cervix, which
illustrate many of the problems which surround the
enthusiastic but unsystematic introduction of screen­
ing, and for cancer of the breast which is currently
being established. We will also consider very briefly
the question of screening for osteoporosis and diabetes.
Screening for psychiatric diseases, particularly depres­
sion, although common to both sexes, is discussed
briefly in Chapter 5.

CERVICAL CANCER
It is claimed that the vast majority of cervical cancers
(theoretically up to 90 per cent) could be prevented if all
women were offered and complied with high quality
cytological screening programmes (Berrino 1988). A
national cervical screening programme was established
in the United Kingdom in 1964.
The current national policy is to screen women aged
between 20 and 64 at least every five years. The 1990
contract for general practitioners (Health Departments
of Great Britain 1989) contains two target levels of 50
per cent and 80 per cent of women eligible for cervical
cytology in general practice. The targets will be
reached and payment made if 50 per cent or 80 per cent
of women aged 25-64 years in England and Wales or
20-60 years in Scotland on a GP's list 'have had an

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SCREENING IN ADUt;

'

'

1EN

adequate cervical smear test during the previous 5-5
years'. Some of the possible difficulties involved in
meeting these targets have been reviewed recently by
Ross (1989).
The Strong Report on the Cervical Cytology Service
in Scotland (1986) recommends screening at intervals of
three years for all eligible women between the ages of
20 and 60 years. The results of a collaborative study of
10 screening programmes in eight countries to estimate
the risks of cervical cancer associated with different
screening policies suggested that screening should be
aimed principally at women aged 35-60 years but
should start some years before age 35 and that intervals
between screening should be three years or less (IARC
1986). The study showed that screening every five
years offered a high degree of protection but appre­
ciably less than that given by screening every three
years. There is little advantage to be gained by screen­
ing every year (Table 19). There seems to be agreement,
therefore, that women eligible for cervical screening
should be those in the age range 20-64, and that
screening should be carried out at least every five years
and preferably every three years.
However, the national programme has not yet re­
sulted in the expected reduction in mortality from
cervical cancer (Roberts 1982, Murphy, Campbell and

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Table 19. Percentage reduction in cumulative rate of
invasive cancer in women aged 35-64 with different
frequencies of screening*

i
i

SCREENING INTERVAL
(YEARS)

% REDUCTION IN
CUMULATIVE INCIDENCE

NO. OF TESTS

~1
2
3
5
10

93^5
92-5
90-8
83-6
64-1

30
15
10
6
3

’From IARC (1986) and reproduced by kind permission of authors
and publishers.

7 CERVICAL CANCER

159

Goldblatt 1988), although as the ICRF Co-ordinating
Committee on cervical screening (1984) pointed out
with the exception of stopping the population from
smoking, cervical cytology screening offers the only
major proved public health measure for significantly
reducing the burden of cancer today.

Various studies have shown that a reduction in
mortality and morbidity is most marked in areas with
comprehensive and systematic screening programmes
such as British Columbia (Boyes el al 1982), Iceland
(Johannesson el al 1982), Denmark (Berger 1979),
Sweden (Patterson el al 1985), Finland (Hakama 1978,
1982), and some areas of Scotland (Duguid el al 1985;
Macgregor el al 1985). In Norway by contrast where
there has been only limited screening, there has been
no demonstrable decrease in mortality (Houge 1980).
And in the United Kingdom where the provision and
quality of cervical cytology programmes varies widely
across the country, the results of more than 20 years of
cervical screening have been extremely disappointing.
Within the United Kingdom, Scotland would seem to
have a lower rate of mortality than England and Wales,
but this is misleading. If figures for the two regions of
Grampian and Tayside, where there are well-estab­
lished screening programmes and more comprehensive
coverage of the population, are removed, the rates for
1978 for the rest of Scotland were similar to those in
England and Wales (Macgregor and Teper 1978).
The reasons for the failure of the national screening
programme in the United Kingdom have been exten­
sively examined and discussed. It is generally agreed
that the problem is not so much of one of money or of
expertise but of organisation, accountability, and com­
mitment (Roberts 1982; Richards 1984). Of course it
is unrealistic to expect that any non-communicable
disease in adults can be completely controlled by
a screening programme as Chamberlain (1984) has
pointed out. There are various points at which a
screening system may fail—it may fail to reach all of the

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SCREENING IN ADULT \yQMEN

CERVICAL CANCER

target population, it may fail to be s^xhciently sensitive
and frequent to detect all cases, it may fail to follow up
all cases detected, and treatment when instigated may
fail to cure or contain the disease. The British system
has been subject to most if not all of these failings.
Effective implementation of screening has various
requirements which have been clearly described (ICRF
Co-ordinating Committee on Cervical Screening, 1984;
Intercollegiate Working Party on Cervical Cytology
Screening 1987; Smith and Chamberlain 1987). In 1984,
the ICRF Co-ordinating Committee on cervical screen­
ing recommended a more organised and systematic
approach. They drew attention to the fact that screen­
ing had tended to be applied differentially to women at
least risk of developing cervical cancer while leaving
those at high risk largely unscreened, and they sum­
marised the extensive public debate on the reasons for
this as follows.
1. Most cytological examinations are performed dur­
ing examinations for obstetric or contraceptive pur­
poses leaving women in the age range of maximum risk
(age 40 years and over) relatively neglected.
2. The length of the prescribed screening interval
(five years) and the lack of clear and well-publicised
arrangements for undergoing examination do not en­
courage women to attend for a smear.
Based on examination of experience in Scandinavia, the
Committee suggested that a successful screening ser­
vice has at least seven basic requirements and these are
summarised in Table 20.
A Lancet editorial (1985) pointed out that most
successful cervical screening programmes have three
main points in common. Firstly, they are organised as
public health, cancer control programmes with the
specific objective of reducing mortality. Secondly, they
call the age groups at greatest risk (those aged over 30
years) and they persist. They concentrate first on
women who have never had a smear and they use
population registers. Thirdly, there is a specific indivi­

Table 20. i^RF Co-ordinating Committee (1984)
requirements for a successful cervical screening
programme*___________ _

160

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3

4
5

6

7

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161

Satisfactory resources for taking, examining, and reporting
on smears
Acceptable arrangements for making and keeping
appointments for examination
Acceptable arrangements for actual taking of smears—for
example, choice between GP or well-woman clinic
Accurate listing of women in target population to enable
complete initial call of eligible women and ensure regular
recall as appropriate
An informed client population who know and understand
the function of the procedure
Continuing scrutiny of records to ensure appropriate
follow-up
Ability to monitor and efficiency and effectiveness of the
programme and to adjust policies and procedures
accordingly

*From ICRF (1984) and reproduced with kind permission of
authors and publishers.

dual in charge of screening who is responsible and
accountable for the programme. In the United Kingdom,
and in Norway, the objectives of screening were stated
in procedural terms—to provide a cytology service—
rather than in terms of outcome—to reduce mortality.
The policy of concentrating on older and never
screened women has not been implemented and it is no
one's specific responsibility to see that it is. 'The blocks
to effective action were neither scientific nor technical
but administrative' (Lancet 1985).
A successful screening service for cervical cancer
must depend, we would argue, on three basic and
practical elements which apply to screening in general.
Firstly, and absolutely fundamental to the success or
failure of the system, there must be an accurate,
computerised data base which is continually updated to
enable the right target population to be invited for
screening and followed up. Secondly, women must be
treated with respect as individuals who are presumed to

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SCREENING IN ADULT ’

^MEN

care about their own health. They must be given the
necessary information about the smear test and its
implications and offered choice of time and location
when invited for screening. If the service wants to
encourage women to be screened, then the onus must
be on the service to make itself attractive, understand­
able, and accessible to the particular population in­
volved. Thirdly, one person in each health district or
health board area must be responsible and accountable
for the screening programme.
These three elements are closely interrelated. The
data base is essential to make sure that all elig ble
women are invited for screening and appropriately
recalled; putting the onus on the service to sell itself to
those invited is essential to ensure high compliance
which should lead to the reduction in mortality that has
so far eluded us; making one identifiable individual
responsible and accountable for screening should be a
guarantee that the system is properly established and
monitored and that the follow-up and quality control
implied in the invitation to be screened is satisfactory.

■H

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The data base
It could be argued with hindsight that the money spent
on establishixig the cervical screening programme in
1964 would have been spent more wisely on creating an
accurate population index for health purposes in every
health district or health board area in the country. But it
is easy and usually idle to argue with hindsight. It is,
however, clear that the age-sex registers of the family
practitioner committees in England and Wales and the
equivalent community health index in Scottish health
board areas are inadequate, and it is now essential fora
government committed to health promotion and disease
prevention to provide adequate resources to create an
accurate, updateable, computerised data base. Begin­
nings have been made and there are islands of excel­
lence but the data base should exist in same form
throughout the country.
As Day (1989) has recently commented

CER VICAL CANCER

163

it is an astonisning aspect of this country's health service
that those responsible for preventive medicine do not
have an adequate list of the population giving age and
sex, and equally astonishing that the lists which do exist
are only for administrative purposes, for use by those
with no medical responsibilities.
This problem is well illustrated in a study in an inner
London district undertaken after district health author­
ities had been instructed to operate a cervical cytology
call and recall screening programme using the age-sex
registers held by family practitioner committees (Beardow, Oerton, and Victor 1989). Out of 686 invitation
letters sent to women by the family practitioner com­
mittees, 477 (69 per cent) were either inaccurate or
inappropriate. Overall, 90 women attended for smear.
Ninety-four letters were returned by the Post Office—
either the addresses were incomplete, the person
concerned had moved, or the building had been demol­
ished. A further 98 women were not eligible for a smear
having recently had one, and one person invited was a
man. The 404 non-responders were sent a question­
naire.
Seventy-five of these were returned undelivered and
255 received no reply—personal visits to the latter
showed that 151 of the women had moved from that
address. Of the 74 women who completed the question­
naire, 41 considered themselves ineligible for screen­
ing, 32 because they had had a smear within the past
three years, five because they had had a hysterectomy,
and four because they were virgins.
As these authors point out, their results, although
possibly exacerbated in a deprived inner city area with
high mobility, do have wider implications for the
success or failure of both cervical cancer and other
screening programmes. About half of the invitations
sent did not reach the women concerned because they
had moved. A further fifth of the invitations were
inappropriate for various reasons. Outside the condi­
tions of a research study where personal follow-up

SCREENING IN ADULT WC>MEN

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visits were possible, these women would have been
wrongly identified as non-responders. It is also of
concern that details of some smears taken within the
past three years had not been appropriately recorded,
ine quality of the family practitioner committees age­
sex registers in England and Wales or the community
health index in Scotland—in theory the most accurate
and extensive population indices available—is funda­
mental to the success of the screening programme and
appears to be gravely deficient. In a study in an urban
practice in London, Rang and Tod (1988) found that 30
per cent of invitations to women eligible for screening
were returned as 'not known at this address', and a
further 45 per cent did not reply. And even in a small
stable general practice population, Ross (1989) found
that between 2 and 4 per cent of patients eligible for
screening could not be traced.
Bowling and Jacobson (1989) have also drawn atten­
tion to the fact that screening will fail if population
Registers are not improved. They cite a recent survey of
the health of all people aged 85 years and over living at
home in City and Hackney Health Authority which
found that two-thirds of 3018 addresses on the family
practitioner lists in 1986 were inaccurate (Bowling
Leaver and Hoeckle 1988). They make the valid point
that between three-quarters and nine-tenths of the
population consult their general practitioner during a
Year and consultation rates are higher among women
and the elderly, both important target groups for
Cnorent screening Programmes and case-finding (OPCS
1986). If receptionists routinely checked patients'
names and addresses when they consulted and immedi­
ately notified changes to the family practitioner com­
mittee or health board, addresses could be updated for
most patients at little cost.
The women at risk
A change of emphasis from putting the onus on women
to seek out the service to asking the service to attract
the women is crucial to success. There is a danger in

< 1 CERVICAL CANCER

165

any large national programme that the concept of the
individual is lost in the mass of tests to be processed and
data recorded. But every woman invited for screening is
an individual in her own particular circumstances with
her own set of beliefs and fears about health and
disease. It therefore seems logical that there is more
likelihood of a woman accepting an invitation to be
screened if the reasons and potential benefits of the test
are properly explained and she is offered some choice in
the timing and location of the appointment. Hiscock and
Reece (1988) found that most of the 91 (4-8 per cent)
patients in their study found to have cervical intraepi­
thelial neoplasia would have been missed if they had
not been actively encouraged to attend for screening,
and in 87 of these, the abnormality was found at an
early stage when treatment offers excellent results.
Standing and Mercer (1984) in a study of cervical
screening in general practice achieved a smear uptake
rate of 96 per cent for all eligible women—100 per cent
for eligible women under 35 years of age, 94 per cent for
those over 35. They acknowledge that the success of
their scheme was helped by having a stable personal list
of patients, most of whom were known to the general
practitioner. Uptake rates are bound to vary according
to turnover rate of patients and their age and social
class. Local factors will also influence the best method
of taking smears. In this particular practice in a compact
urban setting, the nurses backed up by the general
practitioner worked best for effective screening. In
inner cities, family planning and well-woman clinics
may be more appropriate. Standing and Mercer empha­
sise the need for a change in the attitudes of general
practitioners to practical organisation, record keeping
and preventive medicine.
In a prospective, randomised controlled trial in a
group practice with a list of 10,120 patients, Pierce and
colleagues (1989) examined three different approaches
to screening for cervical cancer (1) a traditional screen­
ing approach with all women at risk being sent a written
invitation to have a smear test; (2) a systematic

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SCREENING IN ADULT 'yQtvIEN
opportunistic screening or case-h.xa^g approach with
the notes of eligible women being tagged to remind the
doctor to ask at any consultation about taking a smear(J) an unsystematic opportunistic approach which
relies on the doctor to raise the subject of a smear test
during routine consultation without any reminder in
the notes of eligible women. Not surprisingly they
found that systematic methods of call and recall were
more effective than a non-systematic approach in
encouraging women to have a smear but there was no
significant difference between the two systematic
methods at the end of the year of study.
It has been shown that older women dying of cervical
?nnCer dre
not to have
a cervical smear test
(Ellman and Chamberlain 1984). However, in the study
just described (Pierce el al 1989) the response rate was
not affected by age and the findings suggest that if
women were invited to have a smear test by a doctor
they would accept irrespective of age.
The current failure of the screening programmes to
screen women at high risk seems to be due in large part
therefore, to a failure of the system to tell such women
of the need for a test and invite them for screening at a
convenient time and place rather than from a reluctance
or refusal on the part of the women to respond
positively to the invitation.
® and co-workers (1989) also found that women
who had had a smear test previously were more likely
to respond positively to another invitation. Since more
younger women are having smear tests, coverage is
likely to improve in the future as women who have got
used to the idea of having regular smears and who
regard it as good health practice to do so, move up the
age spectrum.
The question of choice of location for screening is
quite important. There are those who are strongly
opposed to opportunistic screening, partly on the very
legitimate grounds of duplication of testing and over­
load on laboratory staff. However, some flexibility is
surely necessary and opportunistic screening will con-

CERVICAL CANCER

167

tinue to be essential if the system is to try to achieve
maximum coverage. As Cook (1987) has pointed out,
unless screening is treated practically it will still be the
articulate predominantly middle-class women whp will
benefit most.
For women living in the middle of wasteland housing
estates or in country villages with little public transport,
a visit to a screening centre might mean a protracted and
difficult journey, often accompanied by several small
children. In the end it all becomes too much trouble.

i

Rang and Tod (1988), for example, emphasise that
in areas with a highly mobile population, possibly at
increased risk from cervical cancer, the case for oppor­
tunistic screening by the general practitioner and in
gynaecological and genitourinary clinics remains
strong. It is, however, essential to the success of any
screening programme that results are sent to the
general practitioner and information is centrally col­
lated and recorded. They also suggest that women
should be encouraged to take responsibility for their
own screening—each woman screened should receive
a written report with the result of her test and a date
for the next smear. This seems an excellent idea, in
line with the whole concept of making the service
attractive and accessible to women, and similar to the
system of regular appointments with optometrist and
dentist.
Cervical screening seems to be most effectively based
around general practice although in certain areas, such
as deprived inner cities, and among certain minority
groups, a different approach may be necessary. As
Havelock and her colleagues (1988) point out, the
general practitioner is in a good position to offer
information and re-assurance about the test, especially
to older women who no longer attend antenatal, postna­
tal, or family planning clinics and whose opportunities
for screening are therefore reduced. Among other
advantages of a patient being screened in primary care
is the fact that the result will come direct to the general

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SCREENING IN ADULT WOMEN

practitioner, be filed in the patierf**; records and be
accessible at any time (Ross 1989).
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Responsibility for screening
The single factor of appointing one individual in each
health district or board who is responsible for screening
and accountable for the service is one that has been
very much to the forefront in recent discussions on
screening. Various types of health professional are
involved in a cervical cytology service and co-ordina­
tion and communication can slip. The designation of one
responsible person at sufficiently senior level should
ensure smooth running of the system and satisfactory
follow-up and quality control—all implicit in the invitation to be screened.
Preliminary results from a study of a district based
call scheme in East Berkshire in 1986 showed a 25 per
cent increase in uptake of screening in women with no
history of screening (Havelock el al 1988) and suggest
that a co-ordinated scheme with co-operation between
the appropriate health authority and individual prac­
tices can improve coverage substantially.
In terms of follow-up, one of the essential conditions of
any screening programme is that effective treatment is
efficiently offered to all patients with abnormal results.
When screening is actively proposed to asymptomatic
people, the authorities encouraging the screening have a
clear responsibility not only to provide such treatment
but to document and monitor its effectiveness. Elwood
and colleagues (1984) assessed outcome for all 1062
women who had a first report of abnormal cervical
cytology in 1981. Satisfactory follow-up could be found
for only 628 (59 per cent). For 275 (26 per cent) one
subsequent normal smear had been reported but no other
follow-up requested. For 43 (4 per cent) no subsequent
test, after the abnormal smear, had been requested by the
patient’s general practitioner. Thirty patients (3 percent)
did not respond to a request for follow-up. Even after
extensive efforts, outcome could not be established in the
remaining 86 (8 per cent) of patients.

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Kinlen and Spriggs (1978) looked at 101 women in
Britain who had positive cervical smears, but after at
least two years had escaped biopsy. Thirty-one were
untraceable. Among the remaining 70 women there
were 10 cases of invasive and three of micro-invasive
carcinoma. The death rate in the 100 cases was 5 per
cent compared with a death rate of 0-27 per cent in 4097
women in British Columbia treated for intraepithelial
neoplasm grade III or more advanced lesions.
A recent report of the Intercollegiate Working Party
on Cervical Cytology Screening stated that a disturb­
ingly high proportion of women who had abnormal
smears had not been investigated adequately (Sharp el
al 1987), and Singer (1986) has suggested that many
screening centres report satisfactory follow-up and
management for only 60 per cent of cases. Robertson
and colleagues (1988), in a follow-up study of 1347
women with mildly dyskaryotic smears for whom a
repeat smear test was recommended, reported 434 (32
per cent) cases in which the woman was lost to follow­
up before the implications of the abnormality could be
evaluated.
One of the conclusions of an examination of a series of
173 women with cervical cancer in 1982 was that the
follow-up of abnormal smears was poor because of lack
of organisation, commitment, and a clear and consistent
policy (Chisholm 1984).
Thus it seems clear that some women whose smears
are positive are not being adequately followed up and
this is an appalling finding after more than 20 years of a
national programme of cervical screening. It would be
the urgent responsibility of the screening supervisor to
change this, and a recent report of a study in Mel­
bourne, Australia describes a reminder system that
should work in any country that provides screening for
cervical cancer (Mitchell and Medley 1989). These
workers studied response to the recommendation for
early repeat smears in two groups of women whose
initial cytological abnormalities were not considered
sufficiently serious for immediate referral to a gynaecol-

SCREENING IN ADULT WOMEN

CERVICAL CANCER

ogist. If a repeat smear had no.
received within
three months of the recommended date a reminder
letter was sent to the doctor who had taken the smear.
They achieved response rates of 90 per cent and 82 per
cent in the two groups and compliance increased with
increasing age. As these authors point out

which is like.,,! without treatment, to proceed to
invasion. However, the prevalence of truly important
cytological abnormality is probably between 0-02 per
cent and 0-3 per cent—certainly well below 1 per cent.
The prevalence of reported abnormality in most screen­
ing laboratories is higher than this and thus many
innocent abnormalities are being detected which we
cannot distinguish from those that are significant. This
has obvious and important implications both for the
women concerned and for health service resources.
One of the major risks associated with cervical cancer
screening is probably over-treatment at various levels
of severity.
Smith and colleagues (1989) also state that examining
smears when well over 90 per cent are expected to be
normal is very different from examining specimens from
people with important symptoms and an expectation
that many will be abnormal. In almost all simple
screening procedures there will be a high proportion of
false-negative results unless independent re-screening
is built into the system. Few laboratories seem to have
satisfactory internal assessment of quality, and almost
none have external assessment. A serious difficulty also
is that agreement among competent observers is not
good. This would be a clear area of priority for a
screening supervisor and the eventual aim should be
national guidelines and standards of quality control.

170

Achieving high rates of follow-up smear tests and
management in women with lesions that may be precur­
sors for cervical cancer is critical to the success of a
screening programme. Implementing fail-safe systems for
ensuring that such abnormalities are not overlooked
deserves a high priority in the design of screening
programmes.

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We would go further and say that, while no system can
be expected to perform perfectly, a national screening
programme without an excellent standard of follow-up
is unethical.
Quality control is another area of great importance in
a national screening programme. It is not acceptable to
have widely varying standards of service in different
areas of the country. As Berrino (1986) has emphasised,
screening programmes should be backed by effective
quality control systems as well as by the monitoring of
efficacy and side-effects, health education, and standar­
disation of diagnostic and therapeutic protocols.
There are quality control systems in operation in this
country such as, for example, one involving some 16
laboratories in Scotland where three main aspects are
assessed staining and preparation of slides, presence
or not of cells, and reporting. These laboratories are
now using standard forms and terminology at least for
the purposes of the quality control circuit (Mann
personal communication 1989).
As Smith, Elkind and Eardley (1989) have pointed
out, prompt examination of smears demands consider­
able resources—in an average sized district about
20,000 smears a year will be examined. Truly important
cytological abnormality signifies neoplastic change

171

Summary
The national screening programme for cancer of the
cervix in the United Kingdom is still beset by a number
of serious difficulties. The principles of a good manage­
ment system for cervical screening are well understood
(Hobbs el al 1987). It should aim to reach the entire
target population and ensure recall as appropriate. The
invitation to attend should explain the purpose and
implications of the test and whoever is providing the
service should try to deal in advance with women's
anxieties. There should be some choice in regard to
time and location of the test. There must also be prompt
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reporting of results with effective fodow-up and treat­
ment when necessary.
More than enough has been said about the deficien­
cies of the system thus far. It is now necessary to
concentrate on getting it right and the three simple
elements discussed here would go far towards this goal.

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BREAST CANCER
Breast cancer is clearly an important health problem. It
is the most common form of cancer among women in the
United Kingdom and accounts for 20 per cent of all
female cancer deaths and 4-5 per cent of total female
deaths. In 1985 15,000 women in Britain died from
cancer of the breast and we have the highest mortality
rate from the disease in the world.
In 1987, The Government accepted the recommenda­
tions of the Forrest Report on Breast Cancer Screening
and announced the establishment of a national breast
cancer screening programme by 1990. The Forrest
Working Group had concluded that deaths from breast
cancer in women aged 50-64 years who are offered
screening by mammography could be reduced by at
least one-third (Forrest Working Group 1986). They
recommended screening all women in the age range
50-64 years by single view mammography at intervals
of three years. Women over 65 years should be able to
attend for examination if they wish.
The evidence on which the Forrest recommendations
were based came mainly from two large randomised
clinical trials. The first of these was the Hospital
Insurance Plan of New York (HIP study) which started
in 1963 in 62,000 women aged 40-69 years who were
randomly allocated to either a study or a control group
(Shapiro 1977). Seven years after entry into the trial,
cumulative breast cancer mortality in the study group
was two-thirds that in the control group (Shapiro,
Strax, and Venet 1977; Shapiro el al 1982). This
difference between the two groups was maintained up

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173

to the tenth year of the trial, and for cases diagnosed in
the first 10 years, up to the fourteenth year after entry
More recently the Swedish Two Counties Trial in
133,000 women aged 40-74 years has shown a similar
effect over a seven-year follow-up period (Tabar el al
1985). Mortality in the group randomised to screening
was 31 per cent lower than that in the control group.
Updated results recently reported show an increasingly
significant deficit in deaths from breast cancer among
the 77,092 women invited to screening in comparison
with the 56,000 not invited (Tabar el al 1989).
Additional evidence of a reduction in mortality came
from the results of two case-control studies in the
Netherlands. The Nijmegen project (Verbeek el al 1984)
selected women aged 35 years and over for breast
examinations by mammography every two years. The
Utrecht study (Collette el al 1984; De Waard el al 1984)
selected women aged 50-64 years for an initial exami­
nation by mammography and physical examination
with subsequent examinations at increasing intervals of
12, 18, and 24 months. In both studies mortality from
breast cancer was substantially lower in women who
accepted screening than in those who did not.
The first results of the UK Trial of Early Detection of
Breast Cancer were published in 1988. Between 1979
and 1981, the trial enrolled women aged 45-64 in eight
locations around the country. Annual screening by
clinical examination, with mammography every second
year in two of the centres (Edinburgh and Guildford)
and breast self-examination in the other active centres,
was provided over seven years for 45,841 women;
63,636 women were offered instruction in breast self­
examination and were provided with a self-referral
clinic; and 127,117 women, for whom no extra services
were provided, made up the control population. Over
the seven years there was a reduction in the risk of
dying from breast cancer in women offered screening
relative to that in the control group but no difference in
mortality has so far been observed between women in
the self-examination group and controls. The reduction

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in the mammography group was 14 per cent when no
allowance was made for underlying differences in
breast cancer mortality between the populations but
rose to 20 per cent when adjusted for differences in pre­
trial mortality rates. The differences were not statisti­
cally signficant. There was no reduction in mortality
during the first five years. The authors claim that these
preliminary results are consistent with the hypothesis
that screening can achieve a worthwhile reduction in
mortality from breast cancer but stress that further
years of follow-up are needed (UK Trial of Early
Detection of Cancer Group 1988). This is a somewhat
curious statement and the follow-up results will be of
considerable interest.
In a prospective randomised trial in women aged over
45 years in Malmo, Sweden (Andersson el al 1988)
21,088 women were allocated to a study group and
21,195 to a control group. Women in the study group
were invited to attend for mammographic screening at
intervals of 18-24 months and five rounds of screening
were completed. When the trial ended after almost nine
years, there had been no overall fall in mortality in the
study group. But among women aged over 55 years,
mortality fell by one-fifth in women who were screened
despite a lower rate of acceptance among the older than
the younger women. Mortality also fell in the final
years of the trial and just after it finished both in the
whole screened group and in those aged over 55 years.
The authors concluded that their data supported previ­
ous studies showing that invitation to mammographic
screening may lead to reduced mortality from breast
cancer, at least in women aged 55 years and over. Once
again it seems difficult to regard these results as strong
evidence in support of screening.
Experience with the failure of the cervical screening
programme in Britain has led to a determination that the
breast cancer screening programme will be properly
planned, established, and evaluated. But there are
problems as Acheson (1989) has pointed out. In the first
place, although much is known about the aetiology of

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175

breast cancer, it is still not possible to prevent it.
Secondly, available treatment is far from satisfactory in
that about two-thirds of those with the disease are
likely to die of it sooner or later.
The intention in the national screening programme is
that for every population of half-a-million there will be
a screening office as the administrative centre which
will hold details of eligible women in computerised
form, one or more screening units, static or mobile, and
one or more assessment centres with special back-up
services including ultrasonography, radiology, cyto­
logy, and histopathology. It is envisaged that the
system should be organised as part of primary care in
which the general practitioner with nursing support
will have an essential role in inviting women for
screening and giving support at every stage as neces­
sary (Acheson 1989). The Forrest requirements for a
breast cancer screening service are summarised in
Table 21.
Since 1987, when the Government announced the
establishment of the programme by 1990, at least one
screening centre has been set up in each region and
expert groups have been formed to develop guidelines
on quality assurance in mammography and pathology.
The UK Co-ordinating Committee on Cancer Research
is developing protocols lor studies to look at screening
in 40-49 year olds, at the intervals between screens,
and at the question of the number of mammographic
views necessary. These are all important issues on
which clear evidence is not yet available and research
is essential.
As Frost (1988) has pointed out, incidence and
mortality rates rise sharply from about age 30 years up
to the age of 50 years or so and then continue to rise less
steeply. No study has tried to screen women by
selecting those under the age of 35 years for breast
examination because the potential for saving life is
small and the effect of breast examination on women
under the age of 50 years is uncertain. Both in Sweden
(Tabar el al 1985) and Nijmegen (Verbeek el al 1985) no

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SCREENING IN ADULT W^vlEN

Table 21. Foriesl Report requirements for organisation of
a breast cancer screening programme
Women in the target group should be sent a personal
invitation from their general practitioner
2 Arrangements for recording positive results at the basic
screen must include a fail-safe mechanism to ensure that
action is taken on all positive results
3 Every basic screening unit should have access to a
specialist team for the assessment of screen-delected
abnormalities
4 A screening record system should be developed to
identify, invite and recall women eligible for screening; to
record attendance for screening and results; and to
monitor the screening process and its effectiveness
5 There should be adequate arrangements for quality control
both within and between centres so that an acceptable
standard of mammography can be maintained
6 A designated person should be responsible for managing
each local screening service. The person chosen would
have managerial ability and is likely to have experience in
community or preventive health care, although the
radiological aspects must be the responsibility of a
consultant radiologist. Setting up a breast cancer
screening service will require substantial managerial effort
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benefit was demonstrated for women under 50 years at
the start of the trial, but the number of deaths in this age
group was small and the analyses are therefore subject
to considerable random variation. The HIP study
showed no benefit after five years of follow-up, but after
14 years the reduction in mortality seen in those who
entered the trial aged 40-49 years was similar to that in
those aged 50 years or more at entry. It is not yet clear
whether the reduction in mortality seen in those
admitted to the trial aged 40-49 is the result primarily
of the examinations they received after the age of 50
years (Shapiro el al 1982; Day el al 1985; Habbema el al
1986; Frost 1988). Further research is needed to clarify
this.
Frequency of screening examinations is also a valid
topic for research. As Frost (1988) emphasises, decreas-

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177

ing the time between breast examinations must increase
the proportion of cancers found. All current screening
is done first by selecting women above a certain age and
offering examination at an interval between one and
three years. Tabar and co-workers (1985) suggest that
pre-menopausal women should be examined every
12-18 months and post-menopausal women every
18-24 months since the mean detection lead time in the
former is shorter than in the latter. The answers to
questions about the interval between examinations will
come from studies where those screened are random­
ised to different examination schedules varying per­
haps from one to five years.
Forrest recommended a single-view mammographic
examination and this view has been shown to have a
better rate of detection than either the cranio-caudal or
latero-medial views and to be a satisfactory method of
breast examination (Frost 1988). However, since the
cost of mammography is not greatly increased by a
second view and either of the others improves the rate
of detection by about 5 per cent, this also requires
further evaluation.
Although the national programme is being estab­
lished, the debate over screening for breast cancer
continues and there a^e those who remain to be
convinced that this is the best use of resources.
The debate can be divided into two main issues. The
first concerns the practical introduction of screening in
service rather than research conditions—service ver­
sus research. The second relates to the magnitude of
benefit, the use of resources, and the effect on the
women involved—benefit versus harm.
Service versus research
The scientific evidence on which the Forrest Working
Group based its recommendations came from studies
carried out in experimental trials in research conditions
with highly motivated and trained staff and excellent
equipment and facilities. These will be hard to replicate
in normal health service practice.

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Most experts agree that researcn evidence on the
value of breast cancer screening is strong despite
discrepancies when small subgroups are examined
(Ellman 1987). Feig (1988) reviewed data from the five
main trials of mammographic screening and reached the
conclusion that annual, two view mammography with a
physical examination in women aged 40 years and over
could reduce mortality by at least 40 per cent and
possibly by as much as 50 per cent. In routine service
conditions, however, the effect on mortality is unlikely
to be so high—a realistic expectation might be a
reduction in mortality of between 10 and 20 per cent.
Cuckle and Wald (1988) believe that the Govei nment
has allocated sufficient funds for the national screening
programme to ensure a high-quality service, provided
that it is properly organised and directed. Their experi­
ence in the Reading centre suggests that this is possible
and that research can be an integral part of the regular
screening service. They also point out that the screen­
ing centres currently being set up are a new venture in
public health for the National Health Service. They fall
outside the usual structure of medical practice which is
based on general practitioners and hospitals. They must
be recognised as a distinct entity and allowed to
function as such within the guidelines of the Depart­
ment of Health.
Perhaps most important of all, there is the need to
appoint someone who would have overall responsibility
for the screening service. The lack of an accountable
individual with appropriate resources and authority is
largely responsible for the failure of cervical cancer
screening in Britain. Having learnt the lessons from that
programme, Britain now has the opportunity to imple­
ment breast cancer screening effectively from the start.

High compliance is also an important factor in effective
population screening (Forrest Working Party on Breast
Cancer Screening 1986) and response rates of 85 per
cent and more have been reported from Sweden (Tabar
el al 1985) and Holland (Verbeek el al 1984). In the
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United Kingdom thus far, responses have not been so
favourable—60 per cent in Guildford and 61 per cent in
Edinburgh (Roberts el al 1990).
Results of a study in which women were randomly
allocated to a group receiving a letter of invitation to
screening with a definite appointment time or a group
which received an open-ended letter of invitation
suggest that the inclusion of an appointment on the
invitation significantly improves compliance with
screening (Williams and Vessey 1989). This confirms
earlier findings in cervical cytology screening (Wilson
and Leeming 1987) and, as discussed earlier in this
chapter, suggests that treating women with courtesy
and encouraging them to take responsibility for their
own health is sensible policy. In another study in the
South-East London breast screening service, McEwen,
King and Bickler (1989) found that the overall response
rate was 129 out of 283 (46 per cent) women invited but
also found that 99 out of the 283 (35 per cent) did not
receive their invitations. They state that the single
largest contribution to increasing response rates is
likely to be made by a more accurate database and that
general practitioners have an important role in c°un
selling women whom they know have not attended for
screening This study confirms that in inner city areas
with high levels of mobility, high rates of uptake will
take some time to achieve.
Witcombe (1988) suggests the crucial questions are
no longer whether early detection and treatment can
prolong life but how far the quality of screening that has
already been achieved in some research programmes
can be maintained in community hospitals and what
will be the cost to normal healthy women?
Training of radiologists will be essential but this will
not in itself guarantee a good service. Without stringent
centralised methods of quality control, screening wi
be demanded when skills are either not available or are
inadequate. In 1987, some doubt was cast on the time
scale of implementation of the Forrest Report—equip­
ment can be bought but there are not enough radiolo-

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SCREENING IN ADULT ?Z"'S')MEN

gists and radiographers to operate the service and
further training in the specialised techniques of assess­
ment and diagnosis will be required (Ellman 1987Lancet 1987). Further results from the UK Trial of Early
Detection of Breast Cancer must also be awaited with
interest particularly because it is the only population
based study investigating whether the cheaper alterna­
tive of providing self-referral clinics for breast symp­
toms and teaching self-examination reduces mortality
from breast cancer.
There has been extensive discussion of the value of
breast self-examination in diagnosis and Hill and col­
leagues (1988) reviewed 12 separate published studies
which related self-reported premorbid breast self-ex­
amination practices of patients with breast cancer to
disease variables. They concluded that the evidence for
breast self-examination as a worthwhile precaution
which increases the probability of detecting breast
cancer at an early stage is both more consistent and
more favourable than is commonly accepted, and
contend that the data they reviewed provide good
grounds for encouraging women to practise breast self­
examination regularly. Results of current prospective
studies on this aspect in the United Kingdom (Dowle et
al 1987) and the Soviet Union (Semiglazov and Moi­
seenko 1987) should help to throw further light on this.

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In 1985 Skrabanek, in an article entitled 'False Premises
and False Promises of Breast Cancer Screening', con­
tended that screening only adds years of anxiety and
fear to those diagnosed and claimed that

the philosophy of breast cancer screening is based on
wishful thinking that early cancer is curable cancer
though no-one knows what is early.

In 1986 Wright examined data on screening for breast
cancer and concluded that if women submitted to
operation for benign disease are considered to be
harmed by the screening process, then the harm to

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181

benefit ratio could be as high as 62:1. He suggested that
mass screening for breast cancer should be abandoned
and the procedure reserved for women with high-risk
factors. Schechter and colleagues (1986) also claimed
that using a logistic model they were able to define a
high-risk subgroup and that such a selection strategy
might reduce initial visit mammography rates by up to
60 per cent with only a small reduction in case
detection. However, the results of a study by
Alexander, Roberts, and Huggins (1987) suggested that
it is not at present possible to use risk-factor informa­
tion to restrict screening to a high-risk group. And, as
Alexander and co-workers (1988) further point out,
Schechter and colleagues are the only recent workers
to have been optimistic about this risk-factor approach,
their study was restricted to volunteer women in whom
50 per cent of cases have experienced symptoms, and
the complex criteria made it necessary for a woman to
attend for an examination to determine whether she
was in a high-risk category—in such circumstances, it
seems doubtful that the woman in question would
escape screening altogether although she might be
offered a simpler form of screen. Alexander et al (1988)
also emphasise that since it is not known whether a
policy of allocating different recall times in mass
screening would be acceptable in practice, research
would be necessary before any proposal to adopt at risk
strategy as part of public policy could be considered.
In 1988 Skrabanek further commented that the
Forrest Report made no mention of the positive predic­
tive value of mammography, the single most important
piece of information for any screening test. He cited the
Canadian national breast screening study, currently in
progress, where a preliminary report showed a positive
predictive value of 5-10 per cent. The implementation
of the Forrest proposals, with an estimated positive
predictive value of 5 per cent would thus result in
65,000 mammograms a year showing false-positive
results. Skrabanek goes on to point out that the harm of
screening is not confined to overdiagnosis. ‘Overdiag-

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nosis implies overtreatment, unnecessary biopsies, un­
necessary mastectomies, and widespread anxiety’and
fear'.
Reidy and Hoskins (1988) state that, while we do not
know what the optimal positive predictive value should
be, the 33 per cent suggested by figures in the Forrest
report (1986) seems too high, with the risk of missing an
unacceptable number of cancers, and the 5-10 per cent
quoted by Skrabanek (1988) too low, with the risk of
exposing too many women to unnecessary biopsies.
The issues of fear and anxiety leading to an increase
in psychiatric symptoms has also been considered.
Dean and colleagues (1986, 1989) found a small per­
centage of women (8 per cent) who felt that breast
screening had made them feel anxious about developing
breast cancer. This group did have a higher psychiatric
morbidity than their matched control group and it could
be that a small subgroup of women are vulnerable and
that screening has a detrimental effect on them from the
psychological point of view. However, taking their
sample as whole, these workers do not agree with the
suggestion that screening for breast cancer increases
psychiatric morbidity.
Ellman and colleagues (1989) support this finding.
However, these authors stress that their study was
carried out in a well-established screening programme
in which clinical examination was included. The effect
on psychological morbidity of introducing the national
screening programme should be monitored. The com­
ments of screened women indicate the importance of
minimising delays in the diagnostic procedure and of
maintaining full and honest communication throughout.
Warren (1988), in supporting the case for national
screening, states that research results have concen­
trated on mortality statistics but that the benefits of
screening to individual women are wider—namely,
reduced morbidity and more modest surgery because of
earlier diagnosis. This is a very important point and
applies much more widely than simply to screening for
breast cancer. In the new emphasis of screening for

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prevention, we must look for less crude endpoints than
mortality, convenient though this is as a tool of
measuring success, and we will return to this in the final
chapter.
Cuckle and Wald (1988) cite three main areas of
concern relevant to the issue of benefit to harm. First,
there are the special ethical considerations which apply
to screening apparently healthy individuals and these
we have already discussed. Secondly, screening will
identify only about five women out of every 1000 as
having breast cancer at their first attendance and fewer
at subsequent recall visits. This makes it all too easy for
a screening centre to become a dehumanised pro­
duction line—this must be avoided and a pleasant
environment provided to encourage women to attend
and to return. Thirdly, screening itself generates
anxiety. Women who have abnormal mammograms and
are referred for further assessment are likely to be very
distressed and it is therefore vital that appropriate
counselling is available and that screening should
select the smallest number of women for further assess­
ment while detecting a satisfactory proportion of breast
cancers. This mean that we must accept that screening
cannot detect all cases of breast cancer.
Roberts (1989) poses the question as to whether we
are going the right way to provide the best possible
benefit for women? Screening is always a second best,
an admission of the failure of prevention or treatment,
and perhaps resources currently devoted to screening
would be better used for research into an effective
treatment. She quotes Lippman's belief that breast
cancer could be the next human cancer capable of
treatment and his work on measures based on growth
factors (Lippman 1988). In a paper published after her
death from breast cancer in June 1989, Roberts asks
what screening can actually achieve? She also chal­
lenges the ‘currently expressed or strongly implied
statement that if women attend for screening everything
will be all right' and concludes that breast cancer
screening must be brought back into its proper perspeci

184

SCREENING IN ADULT V^MEN

O

tive and we must examine what it is really trying to
achieve in terms of benefit for women with breast
cancer.
In response, Chamberlain (1989), while agreeing that
screening is not the optimal way of controlling any
disease, points out that in the absence of effective
prevention or treatment, it is the third best measure of
control and the best available to us on current know­
ledge. Ellman (1989) feels that the key question con­
cerns the means of keeping costs and emotions inder
control. Some choice in determining how much screen­
ing one has is reasonable and a charge for screening
above what is economically justifiable from a public
point of view would be the fairest and most understan­
dable method of controlling demand. Frankness about
screening is essential. Ellman concludes by stating
clearly that

ip

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r
i

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i
r

i.

i

We will return to this concept in the final chapter.

r

185

far. Eddy (1989), in a discussion of screening in those
below 50 years of age, makes the point that it would be
worth giving the women concerned the information that
is available about the magnitude of benefit and risk and
then asking them how they feel about screening. We
must certainly move away from any idea that screening
per se is bound to be beneficial and towards the
dissemination of more complete information based on
the research findings currently available.
This particular screening bandwagon, however, is
now rolling and will be hard to stop. And, as Asbury
(1989) has pointed out, while many fear that the
programme may ultimately fail, not least because of an
inadequate data base and low compliance, we should at
least try to make it work well.
Among the most important features of the Forrest
recommendations are the insistence on monitoring of
the screening service and its effectiveness, the require­
ment for stringent quality control, and the designation
of one person ’responsible for managing each local
service. These are ingredients which, along with an
improved data base and a courteous and informed
approach to the target population, have been all too
often absent from previous screening efforts and on
them must depend the success or failure of this new
national programme.

the 'free' service seeks to provide a reasonable but not
the maximum possible degree of protection against later
development of advanced cancer and by offering further
screening (with explanation of the pros and cons) to
those who want to spend extra money on it we may be
able to promote more realistic expectations.

Summary
We would place ourselves among those who feel that
there are questions that should have been asked and
answered before rather than after the introduction of
national screening. There seems little doubt that, under
experimental conditions, screening can reduce mortal­
ity from breast cancer by around 30 per cent. We
consider it most unlikely that this can be replicated
under normal service conditions. And of course mortal­
ity is not the only endpoint and a great deal of damage
and anguish can result from an unsatisfactory screening
service. No one has yet adequately measured the
disbenefits of screening, particularly in view of the
number of false-positive results produced in trials so

BREAST CANCER

I

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i

JOINT SCREENING FOR CANCER OF
THE BREAST AND CERVIX
From time to time, it has been suggested that it might be
possible to combine screening for cancer of the breast
and cancer of the cervix on the practical grounds that it
might be more convenient for women to have both tests
at the same time and that it might also prove more costeffective. This has traditionally been rejected because of
the differences in age group and high-risk groups
involved in the two diseases, and at present in Britain the
different recommended intervals between screening.

186

SCREENING IN ADIL

)MEN

However, Roberts and colleagues (1988) in a study of
cervical screening at a breast screening clinic suggest
that it is feasible to carry out breast screening and
cervical screening at one clinic visit and that many
women liked it and found it convenient. If three-yearly
cervical screening were to be introduced as many
people recommend, it would seem reasonable to offer
combined screening to those in the 50-64 year group.
As Roberts and colleagues pointed out, at least 65 per
cent of women attend for breast screening when invited
and the opportunity of offering a smear at the same time
should not be missed. Their experience has also con­
firmed that women in the lower socio-economic groups
are significantly less likely to attend when invited. And,
as Leathar and Roberts (1985) had earlier suggested,
screening might have more appeal for both older and
less affluent women if it were placed in the context of
total health care rather than with the emphasis placed
starkly on specific disease entities.
Certainly combined screening would pose some ad­
ministrative problems to begin with, but once the call­
recall data base had been properly established, it
should be possible, at least in the 50-64 year age group.
It may be that the reasons this has not been officially
considered thus far has more to do with the conve­
nience of those offering the service than with considera­
tion for the preference of the women involved. We
would suggest further that a simple package including
measurement of weight, blood pressure, questions on
smoking habits, and screening for cancers of the breast
and cervix in one visit should be tested for its accepta­
bility to women.
A recent paper from Holland (Habbema el al 1990)
concludes that decision-making processes in which
screening programmes for breast and cervical cancer
are considered separately should be abandoned. For
both conditions, early detection and treatment offer the
best opportunity for mortality reduction in the next
decades. There are very close parallels between the two
screening programmes—both aim at women only and

OSTEOPOROSIS

187

have as their main target the prevention of dissemi­
nated cancer with its almost inevitable consequence of
death. For a woman dying of cancer the untimeliness of
the death rather than the site of the primary tumour is
usually the predominant feature. It, therefore, seems
surprising that planning and evaluation of early detec­
tion programmes for cervical and breast cancer con­
tinue to be done quite separately.

I

I

OSTEOPOROSIS
With the development of techniques such as dual
photon absorptiometry and quantitative computerised
tomography, it is now technically possible to measure
bone mass accurately in the spine and hip (Murby and
Fogelman 1987). Many centres have been established
for osteoporosis screening in the United States but the
value of these has been the subject of much controversy
(Ott 1986; Cummings and Black 1986; Hall 1987). The
US Preventive Services Task Force in its assessment of
the effectiveness of 169 interventions does not recom­
mend routine radiological screening for postmenopau­
sal osteoporosis. Currently available procedures are
time-consuming and require considerable technical
expertise. The costs of screening may be justified if the
burden of suffering from the disease can be reduced but
further research is required to demonstrate both clini­
cal effectiveness and cost-effectiveness. The Canadian
Task Force (1988) is also, against routine radiological
screening for this condition.
Fogelman (1988) raises the possibility of at least one
bone mass measurement for all women at the time of the
menopause to assess whether they have high, average,
or low bone mass. This could identify those most at risk
from osteoporosis—that is, those with a low initial bone
mass. He further states that improvements in techno­
logy in the near future promise higher precision mea­
surements with very much quicker scanning times.
For the moment, we feel it would be difficult to make a

ia8
SCREENING IN ADULT X^OMEN
convincing case for routine screening for osteoporosis
but those at risk should be offered hormone replace­
ment therapy. This is certainly an area to be watched in
terms both of current research into diagnostic tech­
niques and of the outcome of increasing uptake of
hormone replacement therapy in menopausal women

I

i

DIABETES
Diabetes is a major health problem in the developed
world. It has been estimated that the incidence of the
disease is now doubling every decade, and that al­
though dietary habits may be partly responsible for this
increase, the genetic factor is the most important one.
Screening for diabetes, however, suffers from two
important limitations—the lack of an accurate and
practical screening test and the absence of sufficient
evidence that early detection and treatment improve
outcome in asymptomatic people. The main forms of
treatment for mild diabetes—modification of diet and
exercise—are inexpensive and of considerable health
benefit to an individual generally. In Britain there is no
specific policy on screening adults for diabetes.
Recommendations against screening for diabetes in
non-pregnant adults have been made by the Canadian
Task Force (1979) and the US Preventive Services Task
Force (1989). The latter's recommendation states
In persons who are not pregnant, primary prevention
rather than screening may be an important means of
preventing diabetes and its complications.
Bennett and Knowler (1984) confirm that for the
majority of subjects with undiagnosed non-insulin­
dependent diabetes, evidence is lacking that early
detection and intervention are beneficial in preventing
complications or death. They concede that these recom­
mendations may change in the light of various research
projects currently underway.

DIABETES
189
Screening for gestational diabetes is discussed in
Chapter 2. And screening in certain subgroups of the

f

And

Cdn bue °f benefit As Rohan' Frost'

nd Wald (1989) have shown in a recent assessment,
screening diabetic patients for diabetic retinopathy
does satisfy the main requirements for a worthwhile
screening programme. A national screening programme
could prevent over 200 new cases of blindness in those
under the age of 70 years each year and an estimated 60
cases in those over the age of 70.

SUMMARY AND CONCLUSIONS
Screening in adult women includes the two national
screening programmes for cancer of the cervix and the
breast which illustrate many of the problems surround­
ing the whole concept of mass screening.
Cervical cancer screening has failed thus far for
largely organisational reasons. As Johnson (1989) has
pointed out, in a recent review of the literature, the
success of the screening programme must depend on
womens motivation to take part in the screening
process and their acceptance of any subsequent medical
procedure. Better management and careful monitoring
of the system are required and changes to the current
screening programme are essential to provide a service
that can meet women's needs.
In a recent statement on the Edinburgh trial of
HCnnnVin8
1breast cancer, Roberts and colleagues
(1990) reported a non-significant reduction in mortality
from the disease after a follow-up period of seven years;
only 61 per cent of the women initially invited attended
for screening. The authors conclude

The main value of our study may be to draw attention to
the manner in which defects in a programme of screening
can affect mortality reduction. These defects must be
recognised and remedied if the UK breast cancer screen­
ing service is to produce a significant reduction in
mortality from breast cancer in women in its target

SCREENING IN ADU’

WQMEN

O

population. If these defects were to persist we would only
be spending resources recklessly and to little or no effect.

!

i
i
p
}

ig!

Bennett, P. H. and Knowler, W. C. 'Early detection and intervention
in diabetes melhtus: is it effective?’ J Chron Dis 1984, 37:653-66.
Berget, A. ‘Influence of population screening on morbidity and
mortality of cancer of the uterine cervix in Maribo Amnt
(Denmark). Dan Med Bull 1979, 26:91-100.
Berrino, F. ‘Cervical Cancer*. In Elimination or Reduction of Diseases^
n tNJnSlLMAN AnD SHANE P> A- Allwright, (eds) Oxford:
Oxford University Press, 1988.
Blamey, R. W. A Cost-Effective Programme for Whole Population Breast
Cancer Screening.
Bowling, A Le aner, J and Hoeckle, T. Survey of the needs of people
aged 85+hvmg at home in City and Hackney. London: DepartAu?hor°ty ?9m88Unity
CitV
HaCkney Health

With the other conditions mentioned, osteoporosis is
not a candidate for screening at the moment although
with increasing health awareness in the public, imprcwements in technology available for measurement
and diagnosis, and the probable benefits of hormone
replacement therapy, those at risk should be encour­
aged to seek advice. Diabetes, while a major health
problem and by no means confined to adult women
does not satisfy the criteria for screening.
In terms of screening in adult women, therefore, we
would suggest that the emphasis at present should be
on ensuring that the two major current screening
programmes—for cervical and breast cancer—are
effectively organised, administered, and evaluated, and
that there is a positive and acceptable programme of
appropriate health education to encourage women to
look after their health and to support them in their
efforts to do so.

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Warren, R. 'The debate over mass mammography in Britain- the
case for’. Br Med J 1988, 297:969-70.
Williams, E. M. I. and Vessey, M. P. 'Randomised trial of two
strategies offering women mobile screening for breast cancer’
Br Med J 1989, 299:158-9.
Wilson, A. and Deeming, A. 'Cervical cytology: a comparison of two
call systems'. Br Med J 1987, 295:181-2.
Witcombe, J. B. ’A licence for breast cancer screening' Br Med J
1988, 296:909-11.
Wright, C. J. 'Breast cancer screening: a different look at the
evidence!' Surgery 1986, 100:594-7.

,

■/

9

Chapter 2

Design of a Dutch study to test preventive home
visits to the elderly*

Erik van Rossum,' Carla MA Frederiks,’ Hans Philipsen,2 Jeanette Kil-van Lierop,3
Anton Mantel,4 Jacob Portengen,4 Paul Knipschild’

21. Source:

Van Rossum E et al. (1993). Effects of preventive home visits to the elderiyCh.2: Design of a Dutch study to test preventive home visits to the elderly.
PhD Thesis. Maastricht: University of Limburg, Department of Epidemiology
(see also: Nursing Research 40(1990) 185-188).

I

1
2

3
4

University of Limburg, Department of Epidemiology
University of Limburg, Department of Medical Sociology
Public Health Nurses Association of Midden-Limburg
Public Health Nurses Association of Limburg

I

* This chapter is an elaborated version of the article published in Nursing Research 1991; 40: 185-8.

10

Chapter 2

Design

11

-r

Summary

Introduction

Preventive home visits to elderly people by public health nurses or health
visitors aim to assess the functional abilities of aged persons in order to prevent or
postpone health problems and institutionalization. There is as yet no consensus
about the merits of such home visits in the Netherlands, partly because the empirical
evidence is still weak.
This chapter presents the rationale and the design of a study on this subject in
the Netherlands. It is argued that only a study with an experimental design, more
specifically a parallel group randomized trial, can be informative. Next, the selection
of the study population, methods of increasing the comparability at baseline, the
choice of the contrasted interventions, and the outcome measurements are
explained. These issues are discussed with reference to the designs of experiments
conducted previously in Wales and Denmark.

There is a growing interest in the effectiveness of geriatric assessment
programmes (Rubenstein 1988, Kane 1988). In primary health care, medical
screening for specific diseases seems to be disadvantageous (Frederiks 1986,
Buckley and Williamson 1988). There are hardly any diseases to be found in aged
persons which meet the criteria for screening. It is likely that the amount of needless
disturbance and anxiety outweighs the positive effects in terms of case finding
followed by successful treatment.
Instead of screening for diseases, assessment of the functional abilities of
elderly people has been advocated. In this respect (repeated) assessment of the
physical, mental and social functions is considered to be relevant. Public health
nurses* and health visitors are well trained to assess these functions in elderly
people living at home, and they can also give professional advice and guidance.
As in other countries, however, there is no consensus in the Netherlands as to
the usefulness of such preventive home visits (van Rossum and Frederiks 1988).
Those in favour claim it can add to the independence of elderly people, and prevent
or postpone institutional care. Those opposed point at the privacy of elderly people,
and emphasize that the home visits might lead to medicalization and thus to
dependence.

Samenvatting
Preventieve ouderenbezoeken door wijkverpleegkundigen beogen
gezondheidsproblemen en institutionalisering te voorkomen, dan wel uit te stellen. In
Nederland bestaat discussie over het nut van dergelijke bezoeken, onder andere
omdat de beschikbare bewijskracht uit (buitenlands) onderzoek nog gering is.
Dit hoofdstuk beschrijft de opzet van een onderzoek in Nederland naar de
effecten van preventieve ouderenbezoeken. Eerst wordt betoogd dat een dergelijk
onderzoek alleen zin heeft indien het wordt uitgevoerd in de vorm van een
gecontroleerd experiment. Daana wordt ingegaan op de onderzoekspopulatie, de
vergelijkbaarheid van de groepen bij de start van de studie, de interventies die met
elkaar vergeleken worden en de effectmetingen. Deze keuzes bij de
onderzoeksopzet worden toegelicht aan de hand van reeds eerder uitgevoerde
experimenten in Wales en Denemarken.

Empirical research may be of help in settling the discussion. Its performance
seems simple, but, if it is not well designed, the results are difficult to interpret.
Generally, non-experimental studies in intervention research have little value. If
health visitors can decide who will be visited and who will not, they will probably
focus their attention on those elderly people who need the home visits most. As a
result, there will be a clear prognostic incomparability between the contrasted
groups (’confounding by indication’; Miettinen 1985), leading to biased results. It is
an illusion to think that this can be smoothly corrected for with the help of data
analysis techniques. Uncontrolled experiments also give rise to results that are
uninterpretable. If all subjects receive the home visits, there is no contrast. Any
improvement might be caused by the intervention, but also by other factors such as
changing extraneous circumstances.
The performance of randomized trials is the only solution if one wishes to avoid
these pitfalls. Among such trial designs, a cross-over experiment, such as was
performed by Luker in Scotland (Luker 1981a and 1981b), again offers no
satisfactory solution. Among other things, a carry-over effect is likely to occur in the
second period of the cross-over.
For studies on the effectiveness of preventive home visits, only parallel group
randomized trials make sense. By this we mean that the study subjects are
randomly allocated to the experimental intervention or the control intervention (no,
placebo or standard intervention), and that all participants are followed up
simultaneously, measuring relevant outcomes. Fortunately, two such experiments
have already been reported. One was performed in both a rural and an urban area
in Wales (Vetter et al. 1984a and 1984b). The other was conducted in a suburb of
Copenhagen, Denmark (Hendriksen et al. 1984). Both studies were of high quality
and showed beneficial effects of preventive home visits.

Public health nurse
nursing care. A pre\

'he Netherlands execute the task of health visiting as well as that of home
,ve home visit is the Dutch equivalent for a health visit.

12

Chapter 2

Design

13
'y

In the Danish experiment the intervention was found to nave reduced the
mortality, the number of admissions to hospitals and nursing homes, and the
medical care costs per subject. The use of home help and home nursing care had
increased in the visited group. Data on several subjective measures, such as the
quality of life, have as yet not been published. The results of the Welsh study were
only partly consistent: reduced mortality in the urban area only, and a better
functional status in the rural area only, while the subjective view of life seemed to
have improved in both areas. No differences in the use of institutional care were
reported.
It was felt that a replication was needed before definitive implementation of the
preventive home visits in the Netherlands could be considered. In designing the
experiment, we found it very helpful to discuss our study with the Welsh and Danish
researchers. They gave us frank accounts of their experiences and, with hindsight,
the drawbacks of their studies, and they encouraged us to perform a third
experiment.
This chapter presents the design of the Dutch experiment, which aims to study
the effects of preventive home visits on the health status and use of services by
elderly people. A division is made into four sections: (1) study population, (2)
comparability at baseline, (3) contrasted interventions, and (4) outcome measure­
ments. The methodological choices will be explained with reference to the
experiments in Wales and Denmark.

Study population
As in any other experiment, it is desirable to select as homogeneous a study
population as possible. Compared to the previous studies, we decided to use
stricter admission criteria (table 1). Partly based on the experience in these trials, it
was thought that age could bo an effect modifier, having its largest impact among
elderly people between 75 and 84 years of age. Therefore, we restricted the study
population to this age group. To avoid contamination by other nursing care
beforehand, we excluded elderly people and their partners who were already
receiving home nursing care at least once a week. Besides, home visits are not
meant for these subjects, and it was also thought unlikely that the home visits could
have any additional positive effects on these elderly persons.
The study was performed in Weert, a town in the south of the Netherlands, and
some surrounding villages (60,000 inhabitants). This area was chosen, among other
things, because of its clear system of services for the elderly. No major changes in
the environment were expected and no other experiments among elderly people
were in progress (or planned). Moreover, the municipalities and health care services
showed a special interest in the study.
It is clearly advantageous to have baseline information about all participants in
order to control comparability of the groups to be contrasted and for the
measurement of changes of important outcomes. In the Welsh study interviews were
used for this purpose. The Danish researchers, on the other hand, declined to
perform a baseline measurement arguing (correctly in our opinion) that an interview
resembles the intervention and that this may influence the control group (Hendriksen
1986). Advice and even referrals by the interviewer cannot always be precluded, and
these are elements of the actual intervention. We solved this problem by using a
postal questionnaire for our baseline measurement.
The questionnaire was sent out to every person between 75 and 84 years of
age who was living at home (n=1,545). Among other things, the questionnaire dealt

—

—

-------------------------------------------------------------------------------------------- j

with the admission criteria as well as relevant prognostic criteria (self-rated health,
functional status, informal support and use of services). A covering letter explained
what the goal of the experiment was and what was asked of potential participants.
Those interested were invited to return the questionnaire and to sign their informed
consent.
Table 1. Comparison of the study designs in Wales, Denmark, and the Netherlands:
study population.

population

Wales

Denmark

- type

healthy subjects

idem

idem

- recruitment subjects

rural: all ’patients'
from a general practice
urban: random sample of
’patients' from a general
practice

random sample
of the commu­
nity

all subjects in area public
health nurses association

- inclusion criteria

age 70 years or over,
living at home

age 75 years
or over,
living at home

age 75-84 years,
living at home

- exclusion criteria

no

no

home nursing care at
least once a week

- baseline measurement

semi-structured interviews

no

postal questionnaire

- number of participants

n=600 in each area

n~600

n=600

unstratified
randomizationt

stratified
randomizationt

no differences

no differences

unknown

no differences in i.a. self­
rated health, informal
support, use of home
help; small difference in
functional status

- assignment of treatments unstratified
randomizationt
- comparability groups
at the start:
- demographic
no differences
- prognostic criteria
no differences
in function?! status

the Netherlands

t Subjects living together were allocated together to one of the two groups.

The response was quite satisfactory: 85% (n= 1,285) of the approached
population returned the questionnaire.* Of these, 92% reported that they were
willing to participate in the study. After exclusion of those elderly persons and their
partners who were already receiving home nursing care, a random sample of 600
(out of 1,056) subjects could be drawn to form the study population.
This sample contained 20 persons who were found to live in a monastery.
Because these subjects cannot be considered living independently at home (the
monastery provides some domestic services for all inhabitants), we decided to
exclude these subjects after all. Therefore, in the rest of this chapter, we will restrict
the discussion to 580 participants in the experiment.

* Of the 1,545 persons who received a questionnaire, 26 appeared to have died or to have been
institutionalized shortly before the questionnaire was sent out.

---------

14

Chapter 2

Design
15

Comparability at baseline
It is a common approach in experiments to choose a study population and
randomly allocate the subjects to the experimental or the control intervention. In this
way, it is hoped to establish perfect prognostic comparability among the contrasted
groups (no difference in outcome if the intervention does not work). However, due to
random errors bias may easily occur (especially if the study population is not'very
large), unless extra precautions are taken. Therefore, it always makes sense to
prestratify on important prognostic variables, in order to enhance prognostic
comparability. Random allocation within each stratum now has to do with balancing
the unknown or imprecisely measured prognostic variables. Properly measured but
insufficiently balanced prognostic variables can be controlled for afterwards in a
multivariate analysis.
Table 2.

Distribution of some baseline measurements among the intervention and control groups.

characteristic

intervention group (n=292)

control group (n=288)

Randomi^r Of househ°ld’ sel,-rated health, and social class (neighbourhood) ♦
thn^a ridt
WaS pertormed
computer within each of the strata After that
those elderly persons who turned out to have been allocated to the experimental
intervention were once again randomly assigned to one of the three public health
nurses who performed the home visits. In this way, our randomization procedure
was far more precise than the procedures used in the Welsh and Danish studies
ouAo P'est^tlflcatlon '"as omitted (see table 1). The stratified randomization turned
out to be quite successful; the distribution of almost all measured prognostic
variables was equal among the contrasted groups (table 2).
hPtw^Pna?hlr°m thS variables used for Prestratification, there were no differences
etween the groups with regard to informal support, use of home help freouencv of
A?tho loh0’30’5 and fr .equency of recent contacts with the general practitioner
V
though we expected that the prestratification on self-rated health would also
provide an equal distribution of the functional status of the elderly it was found that
as an exception, the experimental intervention group scored slightly better on
«•

-

gender

male
female

42%
58%

43%
57%

age

75-79
80-84

72%
28%

73%

27%

composition of household

'n acucordance with <he experiments in Wales and Denmark it was decided to

alone
together

39%
61%

39%
62%

started5
experlrneri,al mtervention with no intervention, as our trial was primarily
started as a replication of these studies. Hence, at this stage we did noTchooAe to

social class

low
‘medium’
high

27%
61%
12%

29%
62%
10%

self-rated health*

0-5
6-7
8-10

20%
36%
45%

18%
37%
45%

Howeter ^h3'0 eSS'Onai.hOme V'SitS W'th' fOr instance. home visits by volunteers
nn« hfh * h°Te VIS'tS by PUbllC health nurses ,urn out to be effective this
L-f ltyHCa(n Pe considered in a new experiment, which is to investigate the
specific effect of professional versus nonprofessional preventive home9visits
For now, we can only guess at the possible effective elementfs) of the home
offered9andUallty A adV'Ce' referrals' a confidential relationship), since the visA is

0
1-5
0
1-2
3-5

91%

10%

86%
14%

38%
39%
23%

35%
39%
27%

yes
no

19%

81%

20%
80%

informal care available
(if necessary)

yes
no

86%
14%

88%
12%

contacts with GP
in last 3 months

0-1
>1

54%
46%

56%
44%

functional status:**
- ADL disabilities

- household disabilities

use of home help

For self-rated health, or perceived state of health, the participants were asked to rate their health
status on a scale between 0 (poor health) and 10 points (excellent health).
Functional status refers to ADL and household disabilities. With regard to ADL, 5 questions were
asked, related to: walking stairs, bathing, dressing, rising from the bed, and using a normal toilet.
As to the household activities, again 5 questions were asked, related to: shopping, cooking,
laundering, making beds, and mopping/washing windows. For both ADL and household activities

Contrasted interventions

(tabled PaXAnA
°f ‘he inte~antion in the Danish study
table 3). Participants were visited every third month for a period of three vears in
his way the contrast between the interventions was much larger than in the Welch
study (two visits in two years). As in the Danish study the elderly persons could
contact the nurse by phone every day to discuss problems or to ask for an extra

The intervention was comparable to both previous studies as reoards the
study andathPeCtS- EaCh
W3S visi,ed
the
nurse during the entire
the reqult vAtTreXaWvretempl?HyId Specifical|y t0 work
>he study. In addition to
were performed durinn A
T
6 Pa'd '* necessary- N° Physical examinations
iA
v
9 he V'S'tS- lnStead' relevant toPlcs ^re discussed with the

services were “

9iV6n 3nd’ " necessarV’ referrals

a score was computed for each participant between 0 (no disabilities) and 5 points (completely
irity of the municipalities rated each street

°>her '

lt>

Chapter 2

—

Table 3. Comparison of the study designs in Wales, Denmark and th.
compared.

interventions compared

.etherlands: interventions

Wales

Denmark

the Netherlands

no intervention
(usual community care)

idem

idem

- concurrent or historical

concurrent

idem

idem

experimental Intervention
- duration

2 years

3 years

3 years

- schedule of visits
- fixed/flexible

once a year
extra visits if necessary

four times a year
idem

four times a year
idem

- ancillary "therapy"

no; if necessary,
referrals are made

idem

idem

one health visitor
in each area
in care setting,
specifically for study

two health visitors
and a physician

three public
health nurses

idem

idem

control intervention
- active or inactive

- intervention
- performed by

- employment visitors

Contrary to the previous studies (and partly based on the experiences gained in
these studies), a checklist was used during the visit, instead of a problem sheet
(Wales) or an incidentally used questionnaire (Denmark). The checklist contained
relevant topics such as functional and mental status, social functioning, medication,
status of sense organs, informal support and use of health services. In addition,
guidelines for different topics were designed to enable the nurses to discuss topics
systematically and to probe for underlying problems. However, these guidelines are
not meant to standardize the home visits in detail.
An important difference with the Danish experiment was our decision to
continue the visits if participants become institutionalized, and to include all subjects
(living at home and institutionalized) in the outcome measurements. The latter in
particular is of importance. If home visits prevent institutionalization, it is likely that in
the visited group more people with functional incapacities will still be living at home
after three years of intervention. If in the control group persons with an equal
functional status have been institutionalized in the meantime, then outcome
measurements restricted to people still living at home might lead to biased
outcomes.
The control group was left ’untouched’ during the intervention period (except
for a postal questionnaire after one and a half years). However, the subjects in this
group could use or apply for all the regular services in the area as before. The home
nursing care organization in the research area agreed with our request that their
nurses could pay no unsolicited visits during the experiment to participants of the
study. By this, it was prevented that subjects in the control group would receive
similar interventions as those in the intervention group.

Design

-------------------

f

5--------- —------------------------ ------------------------------------ ,

17

necessari'y be based on the precision with which certain measurements can be
made (Feinstein 1977). Furthermore, if several outcomes are intended it is desirable
to distinguish a hierarchy in the importance of the chosen outcome measures.
We determined three categories of outcome measures, combininq the
measures chosen ,n the Danish and Welsh experiments. The primary interest in the
experiment was the effects of the home visits on the health status oHhe efderlv
menteVltalus'feble 4) Tn addT (' a ) Self^ated health' wel|-being and functional and
a' ' ‘ (tabl® 4)- 'n addition, mortality was registered in both groups
To
considered improving the quality, rather than the duration of life, to be
the most important goal of the intervention.
As a secondary interest, data were collected on the use of health care and
welfare services. This information was gathered to see whethe. the visits can indeed
Tr postpoi2e institutionalization. These services included institutional care
(hospital, nursing home, and home for the elderly), as well as the general
hnmTTcT' h°me I161?' and h°me nursin9 care' Third|y' ,he cost effectiveness of the
home visits was calculated for policy purposes.
interva?Mhnfrt'i?POr1ant aSPSCt °f ,h® outcome measurements involves the time
S expect no ZthrT6''2 We
*he intervention P^od from the Danish
study, expecting that three years would be a sufficient period of time to obtain
stTTnth"9 HVTe?K 6 33 t0 'he meritS of ,he home visits- This expectation is
hXl th
/
reSUltS Of the Welsh s,udy' which had an even smaller contrast
between the interventions. If preventive home visits turn out to be effective in our
' 11 WH°Kld be interestin9 t0 see whether these effects last after the
n TXod
rrn° =
ended- ln ,he Danish trial the study population could be
use of slices TheToTal^ d ’T last.intervention with respect to mortality and the
nlhnrt T h T
reduction of mortality was found to disappear during this
den?.on®trated trend of a reduction in institutional care (and hence a
reduction in medical care costs), he -/ever, continued to be in favour of the grouo
which had been visited.* We will perform a comparable follow-up of the study
oneUyea°n
lnterventi°n period has ended, although restricted to a period of

and XeeenToTTrbrelin! meaSUrernent (P°Stal <luestionnaire) halfway through
97% Becaus > of thJ' artdTn
Pen°d' Th® reSp°nse on both measurements was
__i
ki
additional measurement halfway through the study it was not
s±P°fTe t0 ana'yZe d,fferenCeS betWeen the contrasted groups w'h' respect to
the end oHhe'sTT7 T/T0?® measures (se|f-rated health and functional status) at
of the study, but also to analyze the changes over time.
nI1ocrnmary outcome measures that could not easily be measured with the postal
SewsTthe' enTXTnt^
°f m6ntal S,atUS’ Were assessed durin9
nierviews at the end of the intervention period (response 92%) In addition these
a XX o!'aids5^ t0 °baT infdrmation on other health Elated measures, such
TheTntL
prescribed medication, and functioning of the sense organs

Outcome measurements
The choice of relevant outcome parameters should be based on what the main
goal of the intervention is supposed to be. This implies that the choice should not
This information has been obtained by personal communication with the Danish researchers.

uesign

19
r

influenced the intervention process by knowing interim results.

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A ^r.Hf outllne of lhe Dutch experiment is presented in figure 1 By takina into
account the experiences gained in the Welsh and Danish studies, we tried not
merely to replicate but also to improve these studies. As discussed above the main
differences concern the stricter admission criteria, the baseline measurement the
random assignment of the interventions to the contrasted groups, an additional
outcome measurement halfway through the study, the choice of the hierarchy of
o'tco^e6 pa'mmetrl
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----------------

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I S-’

20

Chapter 2

References
BUCkl7±%TX°n/ Wha' S°rt °' ■hea"h CheCkS' ,Or °'der Pe°Ple? Bri,ish

Journal

iyoo, xlc/O, i

Feinstein AR Hard science, soft data, and the challenge of choosing clinical variables in research
Clinical Pharmacology and Therapeutics 1977- 22' 485-98
Frederiks CMA. Preventief geneeskundig onderzoek bij ouderen! pro’s en contra's. Tiidschrift voor
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