Al-Ahram Weekly   Al-Ahram Weekly
15 - 21 July 1999
Issue No. 438
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The age of reason

Old man Has the UN's designatzion of 1999 as "the year of the aged" affected the lives of older people? Halfway through the year, the declaration has put the elderly in the limelight, establishing a new perception of them as givers, not just receivers, of care. But, as Gihan Shahine finds out, there is still much to do for Egypt's ageing population


"The year of the aged?" Seventy-five-year-old Nazli El-Shurbagi has just heard that this year is dedicated to older people. Lying in bed in the secluded world of her Heliopolis apartment, El-Shurbagi suddenly sat up in enthusiasm. Her smile was full of hope: "What does this mean? Does it mean my problems will be solved soon?"

A good question, to be sure, but not an easy one to answer. The UN declaration has probably been good news for the world's older population. Conferences, meetings, seminars, and workshops, both local and international, have been held since the beginning of the year to discuss issues related to the elderly. The media attention is also unprecedented. In cyberspace, a number of web sites allow concerned groups and advocates of older people's rights to vent their views, discuss issues and problems, share experiences and offer new services. And for the first time ever, the World Health Organisation (WHO) chose "The health of the elderly" as the theme for World Health Day last April.

But will efforts go beyond round-table discussions and actually affect the lives of elderly people? Will the problems of people like Nazli El-Shurbagi be "solved soon"? What does helping the elderly entail? Does it mean allocating more money for services geared toward the aged, raising pensions, improving retirement homes, simplifying bureaucratic procedures, fixing pavements and furnishing them with ramps to enable the elderly to go out and providing older people with better health care? Or does it entail a redefinition of the idea of ageing, which will help the aged lead a normal, healthy life?

For El-Shurbagi, 1999 "is just like any other year". Having no children, she has lived on her own since the death of her husband and, soon after, her housekeeper. She then underwent an operation on one leg, which has made moving about very difficult. She could no longer depend only on relatives, neighbours or part-time help. She now needed 24-hour assistance.

"A retirement home was the only solution at the time, but I just couldn't cope with life there," El-Shurbagi recounts. "In rest homes, the rooms are very gloomy and the food is far from good". She waved expansively, the gesture encompassing her elegantly furnished bedroom, in support of her statement. El-Shurbagi decided to leave the retirement home, but since then she has had difficulty finding a good care-giver. "I have a good cook, who also does the cleaning and helps me with daily life, but I also need someone to stay overnight. I feel scared spending the night alone," she complains.

According to a WHO report, the number of older people has risen all over the world due to a sharp increase in life expectancy, accompanied by substantial decrease in fertility. There are currently about 589 million older people in the world. This increase in the senior population will continue and, by 2020, there will be 1,000 million older people world-wide. By 2020, developing countries, with 60 per cent of the older population, will have to cope with the needs of 700 million elderly persons.

In Egypt, 6.2 per cent of the population is above 60. In other words, there are nearly four million Egyptians in that category, a figure that is expected to reach 12 million, representing 10 per cent of the population, by 2030.

"The elderly are growing in number and life expectancy, but we are still far from fulfilling their needs," explains Dr Abdel-Moneim Ashour, professor of geriatrics at Ain Shams University. A UN study conducted in Egypt and other eastern Mediterranean countries has shown that a clear and definitive policy on elderly care is lacking, and that existing services are mainly provided by religious and charity organisations. The study underlines the social implications of such a significant rise in the number of elderly people, which will affect such areas as productivity, consumption, savings and investments, the labour market, types of services required and public spending.

"The absence of a clear-cut policy is alarming since the elderly are expected to receive less family support over the coming years due to financial and social problems," Ashour warns. "Far more social services and qualified personnel will be essential."

Should more retirement homes be built? The very concept has been a bone of contention. Many specialists think Egypt needs more, or at least better, retirement homes, a new trend advocates keeping the elderly with their families through holistic family support programmes.

According to a study conducted by the Eastern Mediterranean Regional Office (EMRO) of the WHO, experts agree that old people are better cared for within the friendly environment of their own families and communities. And in a country like Egypt, where family and religion play a key role, the historical-cultural tradition of family care for the elderly is strong. Both Islam and Christianity stress the fact that caring for the elderly is the responsibility of individuals and the community as a whole, and that being kind and dutiful to elderly persons is an act of obedience to God.

"In Egypt, the majority of elderly people live with their families, yet some still need specialised housing and care," explains Ashour. Recent financial and housing problems, and the emigration of younger generations of Egyptians, have forced many children to place their parents in homes for the elderly. Reliable demographic social surveys are thus needed to reassess actual current family support and estimate future needs. "Again, about 10 per cent of older persons live on their own, and are thus in dire need of professional assistance in their own homes. This service is still hardly available, while many retirement homes are below standard," notes Ashour.

According to official estimates, there are around 77 retirement homes nationwide, 80 per cent of which belong to NGOs and depend mainly on charity and/or residence fees. Some homes offer free or subsidised services, while higher-quality homes may demand as much as LE800-LE1,000 a month.

But the total number of retirement homes does not host more than one in a thousand older people in Egypt. Their capacity rarely exceeds 40 persons per home, and most are located in the governorates of Cairo, Alexandria and Al-Gharbiya. Most have poor facilities and little or no qualified personnel, according to a study conducted by the National Centre for Social and Criminological Studies (NCSCS).

"Retirement homes have become a necessity of life today, a fact that we can no longer ignore," says Hatem Abdel-Azim of Dar Ibn Hani', a home for the elderly affiliated to an Islamic charity association in the district of Imbaba. The facility, where fees range between LE100 and LE150 per month, houses 34 elderly persons, with another 100 on the waiting list. Eight residents are exempted from residence fees since they have no financial resources, according to Abdel-Azim. "Most of the cases we have here are widows or widowers who, for financial reasons, had to leave their apartments to their married children. Others couldn't move in with their children because they wanted to avoid problems with their sons- or daughters-in-law," he explains.

Hagg Ali Hussein, a retired educationalist, is a case in point. After his wife's death, Hussein moved in with his son, but couldn't get along with his daughter-in-law. He then thought of moving to a retirement home, where he says he enjoys "peace of mind and the company of other residents. I think retirement homes are such a good idea; I see no reason why they should be socially stigmatised," says Hussein, nervously fingering his prayer beads. "Since this is the year of the aged, we expect the government to build more and better facilities for the elderly."

And why not? This is a small price to pay. The elderly people in question, after all, are our parents and grandparents. They took proper care of us when we were young. It is only right that we give them all the care they need as they advance in age.





photos: Khaled El-Fiqi, Randa Shaath
Marie Khalil, head of the Ministry of Social Affairs department that is responsible for the elderly, admits that there are not enough retirement homes. Many of those that do exist, furthermore, are below the required standard. "Funds are to blame here," Khalil concedes. The ministry gives financial support to around 20 homes and provides all homes nationwide with social workers and trainers, "but housing for the aged is very costly," she argues. "One person costs a minimum of LE500 a month, so we need at least LE300,000 a year to cover the expenses of 50 persons in one facility, let alone the price of the land and the building. How can the ministry or even an NGO afford it?"

Still, Khalil adds, the ministry is drawing up plans in line with the new global trend that encourages keeping the elderly with their families. "Our primary objective now is to train one or more family members to be caretakers," says Khalil. "The programme also includes setting up more offices that extend services to elderly people at home. Today, we have only four, two of which are in Cairo, offering the elderly such services as making an urgent call to a doctor, providing hot meals, or sending a part-time caretaker."

A number of NGOs have also taken the initiative in providing home services for the elderly. The Coptic Evangelical Organisation for Social Services (CEOSS), in cooperation with the Centre for Geriatric Services (CGS), an organisation based in Nasr City, and Al-Salam Hospital of Mohandessin, have designed the Care with Love Programme, initiated by Dr Magda Iskandar, health consultant with CEOSS, and aimed at providing services to older people at home while creating employment chances for youths. The project, which started three years ago, provides training for unemployed recent graduates in primary care and first-aid measures in order to qualify them as home health-care providers (HHCP). "The project has proved successful so far, and we have partly solved the problem of homes that have no room for more occupants," says Dr Maged Moussa, director of the CGS. The service, however, is affordable only to middle- and upper-middle class people. Similar services will be essential for the poor.

More homes and better facilities, however, are not what the International Year of the Aged is all about. On World Health Day last April, the WHO focused on how "active ageing makes the difference". This theme, as Gro Harlem Brundtland, WHO director-general, explained, "recognises that it is key for older people to go on playing a part in society". In a brochure issued on the occasion, Brundtland explained that "older people are often viewed as a homogenous group from mainly industrialised countries, who no longer contribute to their families and societies and may even be a burden. The truth could not be more different. The majority of older people prove these notions wrong every day, and it is an example that has inspired the WHO to focus on ageing."

This was also the conclusion of a three-day conference on ageing held by Ain Shams University's Centre for Counseling (CFC) and Geriatrics Department, under the auspices of Mrs Mubarak. "The conference stressed the fact that older people can make innumerable contributions to their families and societies," says Dr Talaat Mansour, head of the CFC. The UN General Assembly considers 60, when many people retire, to be the beginning of old age. Many septuagenarians and octogenarians, however, show few or no symptoms of ageing and are eager to go on giving. Proof of this can be found in many agricultural communities, where most elderly people, men and women alike, continue to work in farm production until they are physically unable to carry out their tasks, which is often very late in life.

"In industrial communities, however, people start to feel useless upon retirement, and many even show symptoms of depression due to the widespread misconception that ageing means awaiting death," Mansour says sadly. "The truth, however, is that the elderly phase signifies the peak of experience and the acquisition of a wisdom society needs desperately."

To achieve the dual goal of dispelling depression and benefiting society, he argues, elderly people should continue to work. Continued activity is also important in avoiding, minimising, or reversing many of the physical, psychological and social hazards which often accompany advancing age, according to the WHO brochure.

Should the age of retirement be delayed? This has been the topic of the year, with many people around the world voicing their objection to enforced retirement. An organisation has been set up in the US to defend the rights of elderly people, particularly the right to remain employed as long as one is able and willing to do so. In Egypt, the Ministry of Social Affairs is considering the matter but, as Khalil explains, since unemployment is relatively high, it is difficult to make such a decision. Older people, she believes, should make room for the younger generation.

"Post-retirement re-employment is a suitable solution," said Mansour. "The elderly can be instrumental in volunteer and social work. The country should involve retired persons in such projects as eradicating illiteracy and family counseling. The elderly can also work in nurseries or orphanages since they are usually very patient and compassionate with children, who show equal affection for grandparent figures."

Income and health, however, remain two main obstacles to the application of "active ageing" programmes in Egypt. "Health is vital if older citizens are to continue contributing to society," says Ashour. "Access to health care is important, to enable those advancing in age to maintain their capacity to work, and to ensure that children grow up into healthy adults able to participate productively in society."

Health policy must therefore be based on a life-cycle approach which tackles health problems from the very start, enabling people to grow older without disabilities and chronic diseases, according to the WHO study.

In line with that approach, the Ministry of Health has adopted a "family doctor" programme, which includes training general practitioners in the provision of medical services to all family members, especially mothers, children and ageing parents.

"Still, there should be more focus on geriatric medicine," Ashour argues. "It should be part of the curriculum in all medical schools."

Geriatric medicine as a specialisation was introduced to Egypt in 1982 by Ashour, who studied medicine in Europe and the US and came back to establish a geriatric medicine department at Ain Shams University. Since then, other universities have contributed to the field.

"Long-term programmes should also be designed to be applied in both homes and hospitals," Ashour adds. Alzheimer's, for example, is one of the most disabling diseases and needs 24-hour care. This disease is on the rise in Egypt, with a current number of 100,000 patients, expected to reach one million by 2030. "Egypt is still unprepared to cope," Ashour notes.

Specialised health-care programmes of the sort are very costly, however, given that resources are already limited. Many experts expect that competition for resources will continue, with demands for more resources focusing on maternal and child health, or to large-scale public health programmes. Such areas, they argue, should have a higher priority than special health care for the elderly.

Khalil boasts that the Ministry of Social Affairs has recently given older persons more attention, establishing a higher committee for elderly affairs, laying the groundwork for a database, designing new special care programmes for the aged, and communicating with the media to increase public awareness of their problems and needs. She agrees, however, that limited resources are always a major obstacle to the application of the ministry's plans.

One programme under trial is early rehabilitation before retirement. The programme, Khalil's brainchild, is designed to help those approaching retirement to cope with their new lives. "I started with training my colleagues in the ministry, and I hope the idea will be adopted by other institutions," she says. The programme should provide information on a healthy diet and the exercise necessary to maintain well-being and a high quality of life after 60. The programme also helps those interested in setting up a private business to carry out feasibility studies for small-scale projects.

Pensions, too, are still a major problem. "The income of the elderly after retirement is usually very low, especially when compared to the ever-increasing cost of life," Ashour laments. Khalil, however, argues that pensions increase every year, with bonuses during the feasts. The Ministry of Social Affairs offers the elderly reduced-cost public transport and entertainment (at theatres and exhibitions) -- but this privilege is rarely obtained due to long bureaucratic procedures and lack of funds.

"A national fund should be established to cover these expenses, and money should come from charity as well as the public and private sectors," Ashour maintains. "The environment is not aged-friendly, and greater efforts should be exerted to provide streets with ramps and lower sidewalks. These measures would enable the elderly to go out and lead a normal life. Perhaps we need a decade rather than just a year for the aged."

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