JAN BAARS AND KEES KNIPSCHEER
AGEING IN THE NETHERLANDS: STRUCTURAL
AND CULTURAL CHARACTERISTICS
ABSTRACT. This article discusses the specific situation of social policy for the elderly in the Netherlands. On the one hand, due to a prolonged high birth rate after the Second World War, the proportion of the aged is relatively moderate in comparison with surrounding countries. On the other hand, more aged people live in intramural institutions than in other ¢ountrles, which contrasts with the availability of informal care, resulting from the relatively large proportion of younger persons. Some possible explanations for this paradoxical situation are explored, especially the competition between the different social "pillars" in Dutch society during the expansion of the welfare state. Key Words: demographic developments, social policy for the aged, welfare state, social pillarlzatlon.
INTRODUCTION For a number of years there has been a growing awareness of the very specific situation in the Netherlands with regard to social policy. Since the sixties, the Dutch welfare state has achieved one of the highest levels o f welfare in the world. The public social insurance system provides an income at the minimum standard o f living for all residents; there is a highly developed health care system and a special health insurance system for all the disabled, old as well as young. O f course, also in the Netherlands, these arrangements have been threatened lately by the financial problems of the government. Within this context, policy for the elderly seems to be a special case. In the next section (A), a statistically based picture will be presented o f the ageing of the population in the Netherlands and of the policy for the elderly as developed over the last decades. Special attention will be given to the growth of professional care for the frail elderly in relation to the availability o f informal care for them. The interrelationship between both seems to be paradoxical in the Dutch situation. Subsequently, in section (B), we will explore several explanations for this paradoxical situation. A. The Paradox: Ageing, the Family and Services f o r the Elderly. Ageing can be studied at the level o f the family, at the level o f organized institutions and at the level o f society. Each has its special focus, but each of them is interrelated and has to be kept in mind to develop a balanced picture. It is the intention o f this section to develop such a picture with special attention to Journal of Cross-Cuhural Gerontology 4: 129-142, 1989. © 1989 Kluwer Academic Publishers. Printed in the Netherlands.
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the amount of institutional services developed for the elderly and the availability of family members to care for the elderly. The first step is to show that the Netherlands have, in comparison with many other Western European countries, a low percentage of people of 65 and over. The figures in Table I show the difference. Most countries hover around 13 or 14% elderly, while the Netherlands is the lowest of the presented countries with 10.7% in 1975. This low percentage of elderly is related to the general TABLE I The growth in the percentage of people above 64 years of age in some Western European countries
West Germany France Italy Netherlands Belgium United Kingdom Denmark Luxembourg
1975
1990
2005
14.3 13.3 12.0 10.7 13.9 14.0 13.2 13.0
14.5 12.7 13.5 12.3 13.0 14.8 14.7 12.9
17.1 13.8 15.2 13.3 13.7 13.9 13.7 15.3
Source: Commission of the European Communities. The
economic implications of demographic change in the European Community, Brussels, 1978. demographic composition of the Dutch population. Because of a very high birth rate up to the end of the sixties, the relative size of the older cohorts is small. The Netherlands has one of the highest birthrates up to the end of the 1960s. (Bevolkingsstatistiek EG, 1982.) This implies - and this is our second point that on average, the families in the Netherlands are bigger in comparison with other Western European countries. In the last decades, older people in the Netherlands had more family members available for support than in other countries and this will be the same for the next decades. This means, for example, that for the elderly in the year 2000 a relatively large number of children between 40 and 60 will be available to care for their older impaired parents. It has been demonstrated that caregiving for older parents by adult children is, in accordance with the traditional division of labor between the sexes, in the large majority (95%) of cases still a task for daughters. We do not imply that this situation is normal, nor that it must necessarily be continued. Should this pattern be continued, however, then the availability of daughters remains relevant. In Table II, the findings of a prospective study are summarized, showing how after 2010 the drop in the birthrate of the seventies will result on the average, in a considerably lower number of daughters available to care for older women.
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TABLE II Average number of expected daughters in The Netherlands of women 50, 60 and 70 years of age frum nine cohorts beginning in 1910 years
cohort
1980
1910 1915 1920 1925 1930 1935 1940 1945 1950
1.28
1985
1990
1995
2000
2005
2010
2015 2020
1.31 1.31
1.29 1.25
1.25
1.24 1.24
1.16
1.23 1.16
1.03
1.15 1.03
0.93
1.02 0.93
0.86
0.92 0.86
0.85
Source: Bartlema, Knipscheer, Poppel van (forthcoming). The availability of adult children to care for their parents is not only dependent on the number of children, but also on their involvement in other activities. One of the main activities which may prevent adult daughters from taking care of their impaired parents is their participation in the labour force. In general, this participation has increased since the second World War in all Western European countries, but not at the same rate. The Netherlands are, astonishingly enough, one of the countries in Europe with the lowest proportion of women in the labour force. Of those women between 45 and 60 years old, no more than about 24% are active in the labour force. In France, the United Kingdom and Denmark, this participation is up to 60 or 70%. The Netherlands' lower proportion of elderly, larger families and more time available among the daughters of older people, means that in the last decades the Netherlands had, on the average, more informal caregivers for impaired older people available than most other Western European countries. Given this situation, it is the more remarkable that (in the same period) the number of old people in institutions has grown disproportionately in comparison with other Western European countries. Collot et al. (1982) presented percentages of older people age 65 and over in communal accommodations (excluding hospitals) in several European countries: Belgium 5%, Denmark 7,9%, France 5%, Greece 1%, Ireland 3,6%, Luxembourg 4,7%, Fed. Rep. of Germany 4,5% and United Kingdom 5%. Comparing these percentages with those for the Netherlands presented in Table III reveals the high proportion of older people in the Netherlands in intramural care, in a home for the aged or a nursing home, over the fast few decades. A home for the aged is a collective housing facility for older people who have some Irouble with maintaining an independent household. When these people
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TABLE IH Number and proportions of older people in The Netherlands living in institutional settings
1965 1970 1975 1980 1984
homes for the ageda
nursing homes
69.431 105.161 131.993 133/323 132.562
9.318b 17.312e 33.958 d 39.456 e 40.433 f
5,7% 7,8% 8,9% 8,1% 7,7%
0,80% 1,30% 2,27% 2,40% 2,33%
" Statistiek van de Bejaardenoorden 1965, 1970, 1975, 1980 en 1984, CBS, 's-Gravenhage/I-Ieerlen. 1, Overzicht gegevens verpleegtehuizen in Nederland. VAR-reeks, jaargang 1969, no. 10, Uitg. Ministerie van Sociale Zaken en Volksgezondheid. c VAR-reeks jaargang 1974, no. 8, Uitg. Ministerie van Volksgezondheid en MilieuhygiSne. d Statistisch Zakboek 1987, CBS, Heerlen. apply for a place in a home for the aged and are admitted, they get a private room and full service in household affairs (cooking, cleaning) and sometimes some personal care (washing, bathing, clothing), but no daily nursing care. However, the government no longer builds new homes for the aged, and the "full service" provision in existing homes for the aged has been changed to "needed service". Those who need nursing care because of chronic conditions now go to a nursing home. Over the years a distinction has grown up between somatic nursing homes and psychogeriatric nursing homes. Somatic nursing homes offer, in addition to the services for chronic patients, rehabilitation programs for those who are recovering from strokes and accidents. Rehabilitation patients live temporarily in a nursing home, about 20% of the beds in nursing homes being occupied by them. How can we understand this high proportion of elderly in institutions in the Netherlands? Did the Dutch family shirk its responsibility for the older family members? Has the Dutch government promoted such a high standard of institutional care facilities that it seems to be attractive to live in them? Or is there a lack of professional home help and home care? This last suggestion may be explored based on some comparative data. Table IV presents some figures on the availability of professional home help and home care for the elderly in some European countries. The Netherlands appears to be well developed in this area of services for the elderly too. Dutch care for the elderly, therefore, indicates - more implicit than explicit a trust in institutional professional care. Since the Second World War institutional care was promoted, and only recently, because of lack of money as well as because of changing views concerning institutional care, was a more restrictive policy implemented. The next section of this paper will explore some cultural explanations for this
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TABLE IV The availability of professional home services for older people in some countries in percentages.
getting home help getting home nursing sheltered housing hospital beds per 100 65+
England
Scotland
9.0 17.7 6.0 2.0
7.7 12.9 2.6 2.0
Norway Israel 6.2
2.5 10.0 1.7
3.9
Netherlands 10.0(1976) 9.7
Source: International Social Security Association, long-term social care and social security, 1984.
situation. The focus of the explanations will be on the Dutch civilization and its connections with the development of the Dutch welfare state over the last decades. B. Towards an Explanation of the Paradox: Cultural Developments in the Netherlands
At first sight it may not be clear how cultural factors could help explain the paradoxical situation in the Netherlands. The amount and quality of the service for the elderly seem to be directly affected by the turbulent developments concerning the fate of the welfare state. Not only the political initiation and expansion, but also the later crisis, of this compromise of social-democratic and capitalist orientation show an international synchrony (Guillemard 1983), which points to the macro-economic processes that made the welfare state possible and also caused its decline. This synchrony corroborates Wilensky's thesis, that not ideological or cultural factors, but the rate of economic growth, determined the development of the welfare state and also, it may be added, its decline (Wilensky 1975). The institutional arrangements of the welfare state differed, of course, nationally, depending on the cultural traditions involved and these still partly shape the problems that have to be dealt with when the arrangements of the welfare state decline. In this perspective, we want to pay attention to the typical Dutch constellation of "pillarization". Pillarization
The typical, though not exclusive Dutch phenomenon of pillarization consisted of four competing social blocks that were clearly separated from each other and internally vertically controlled.* * See Note Added in Proof on p. 141.
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The four pillars, a Roman Catholic, a Protestant, a Socialist and a Liberal one, tried to imprint their specific character on all spheres of social life. Not only would people (especially from the competing denominational blocks) not marry someone from another pillar, but they would also have their own schools, newspapers, libraries, read their own newspaper, be a member of their own radio & TV-organization, vote for their pillar-leaders, buy books from their own pillar-publishers in their own book-shops and would also, of course, organize the care for the elderly on their own pillarized basis. In the southern part of the Netherlands, where the majority of the population traditionally belonged to the Roman Catholic Church, the pillarized structure was (and to a large extent still is) in a homogeneous way, present in many spheres of life. In other parts of the Netherlands however, the national pillarization manifested itself at the local level. In a larger village there would be Roman Catholic, Protestant and General football-clubs, schools, libraries, etc. People would buy from their fellow greengrocer and the Protestants would even be very sensitive regarding the differences between denominational subcultures within their own pillar. The impulse for the creation of the pillars came from the denominational groups, who had different political aims, ranging from an emancipation from their minority position to a religious neutralization of the socialist movement. In their energetic struggle they shared the first objective: organizing elementary schools on a denominational ("special") basis. As a result of these efforts, in 1945 70% of the elementary schools were organized on a special (Roman Catholic or Protestant) basis, whereas in 1890 this was the case for only 20% (Van Doom 1978). The struggle for "special" education extended to universitylevel (a Protestant university was founded in 1880 in Amsterdam, a Roman Catholic university in 1923 in Nijmegen), where even a Protestant and a Roman Catholic philosophy of science guided the efforts in education and research. The struggle for emancipation manifested itself also in a strong encouragement of a high birth-rate, especially in Roman Catholic families (Van Heek 1954), supported by the general allowances for children since 1939. This policy had especially strong results after the second worldwar. Besides school-education, the denominational pillars were especially active in those social areas that were more or less a direct continuation of the traditional charity of the church. And in spite of the later de-pillarization, the denominational organization is still - at least formally - dominant in institutional care for the physically or mentally handicapped and for the impaired elderly. Ideologically, the pillarized policies were legitimized by the Roman Catholic principle of "subsidiarity", and by the Protestant principle of "sovereignty in one's own sphere". The principle of subsidiarity meant that affairs that are settled at a lower level are not to be re-examined at a higher level. This principle was also meant for affairs within the pillar itself (notwithstanding the fact that clerical hierarchy ruled supremely), but functioned primarily as a way to protect the pillar from intervention by the national government or by other pillars. Also
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this principle implied that the state should only be active where and as long as private initiatives had not been developed, and that the state should withdraw as soon as this was the case. The Protestant principle of sphere-sovereignty had an analogous meaning. It follows, therefore, that the Socialists and the Liberals were not the active parties in the process of pillarization. The Socialists were, of course, much more inclined to encourage state-activities, but nevertheless developed their own pillar-like forms, insofar as they wanted to distinguish themselves from the other pillars and from the ruling capitalist state. The Liberals, to the contrary, would support this capitalist state, but were inclined to restrict its activities. Socialists and Liberals were more or less forced into the pillarized structure and found themselves often together (for instance in the case for general schools), in their opposition against the denominational pillars. The pillarized social structure became the national vehicle of emancipation and internal integration, flavored by a strong Dutch tradition of moralization, which was shared not only by the Catholic and Protestant pillars but also by the Socialists and (maybe a little less) by the Liberals.
Pacification and Cooperation The four pillars, though, had to acknowledge each other's existence and had to face the reality of not being able to make the whole country into a Protestant, Liberal, Roman Catholic or Socialist nation. At the top of the pillars, the mutual leaders developed a solid consensus about the national political aims after the Second World War. These were, first economic reconstruction and industrialization, and after that, the development of the welfare state, coordinated by the 1952 inaugurated "Department for Social Work" (Ministerie voor Maatschappelijk Werk). The pillars cleverly let the state finance the activities that were controlled by their own organizations. Especially after 1950, the welfare state grew at an increasing rate through the pillarized institutions that competed with each other at the state's expense. Moreover, the institutionalized rule of "three of TABLE V Denominational orientation of homes for the aged in The Netherlands in 1987a Catholic oriented (KvB) Protestant oriented (PVIB) Humanist oriented (HSHB) Public/general (AIVB) Not known
587 457 41 403 62 1550
a Based on personal information.
37,8% 29,5% 2,6% 26,0% 4,0% 100%
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each" implied that there should be a Roman Catholic, Protestant and General version of each subsidized institution. Some information on the denominational distribution of the homes for the aged in the Netherlands is given in Table V. The opportunistic policy of the pillar-elite was in a way a foreshadowing of the "immoralist ethos" that is often supposed to be related to the welfare state and which will be discussed later. Once the rate of economic growth enabled the expansion of the welfare state, the pillars were able to organize in a relatively short time and on a national scale, the arrangements that they thought were necessary. Also the institutions of intramural care for the elderly could be organized quickly, drawing on the potential for leadership and professions that was present in the pillars. The Horizontal Void
Inherent in the pillars was a strong hierarchic structure of leadership. The principles of subsidiarity and sphere-sovereignty functioned especially (as has been stated above) to protect the pillar from external interference. It did not mean that each level of the pillar had the right to make its own decisions. Above all there was the strong leadership of the bishops or other denominational boards of management, represented at every level by the priests or the reverends and their wives, who were honored guests and leaders at most public activities. Apart from this organized presence of the leading clergy at every level, there was a strongly internalized obedience towards the church and its leaders, complemented by social control. As a consequence, caregiving tended to be vertically organized, led firmly and centrally. The pillarized "top down"-organization left little space for horizontal community-care. Therefore we cannot find in the Netherlands large voluntary organizations such as the British Age Concern or the Abbeyfield Society. And, also, in families the responsibility was dictated and shaped by the clergy to such an extent that a tradition of care that was independent from religious doctrine had difficulty in developing. But during the sixties the process of secularization manifested itself clearly in the political composition of the Netherlands. The two denominational pillars that held a solid marjority after the Second World War until the elections of 1967, have received since the early seventies only a third of the votes. As a result of the created horizontal void, the secularization and the ensuing rebellion against the church and its paternalistic organizations, the structures of communal life and family have been affected to such an extent, that some observers have spoken of an "immoralist" ethos. The opportunistic strategy of the pillar elites thus turned out to be a trap. It turned against the strategists as the state gradually gained more control of the activities that it financed. The outcome, generally speaking, being that the institutions that were once seen as the embodiment of the specific emancipationary movement lost their internal traditional force.
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The result of the absorption of the piUarized institutions by the expandin~ welfare state is the return - in a historically changed setting - of the individualistic society that the denominational and socialist pillars had set out to fight. This not only can be seen in the traditionally Christian institutions under the influence of the broader process of secularization that takes place in Western culture, but also in the socialist movement. The social democratic policy of creating a socialist nation in the form of a welfare state has emptied the socialist inspiration and has focused political attention on fighting for the privilege of governmental finance. The organizations of politically active elderly have had very little influence on social policy in the Netherlands. Here also the organizations developed within the patriarchal pillars and were dominated by them. The pillarized elderly-organizations, the Roman Catholic "Unie KBO", the Protestant "PCOB" and the general "ANBO" traditionally had great difficulty in cooperating because of the profound differences that were thought to exist between them. For several years, though, these organizations have been united in the COSBO and it is to be expected that the elderly will be more active and will have more influence through this organization in the years to come. Maybe even more important are the rapidly growing number of initiatives of elderly people concerning the self organization of their situation.
Institutional Developments in Social Policy Regarding the Elderly In addition to the foregoing, several additional factors have influenced the relative high percentage of elderly people living in institutions for intramural care. First, since the fifties we can observe an increasing tendency to leave the shared household of the multigenerational family, where that still existed. The allowances for the elderly made them less dependent on their family and enabled and encouraged them to live separately. On the other hand, children tended to marry young and, because of the expanding economy, were able to support their own household. This resulted in the long sustained high birthrate and the increased tendency to live in separate households after the second world war. In turn, in the densely populated Netherlands, this created a shortage of houses, which the government tried to relieve by building large homes for the aged. The expansive strategy of the pillars in the area of social care harmonized with this policy to relieve the housing problems. Later evaluations showed that this policy had various detrimental effects. The publications by Van den Heuvel (1973) and Ten Have (1979) indicate growing doubts about the former idealization of institutional housing of the elderly to meet various categories of need. Socially, there was the strong disadvantage of isolating elderly people t~om younger people; moreover, once the home for the aged has been entered, it turns out to be difficult to leave it, to start to live independently again. Gradually, as the inhabitants grew older and relatively few younger ones
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entered the homes, the atmosphere in the homes for the aged changed. The physical fitness and growing self-confidence of the "new old" contrast more and more with the character of the intramural settings for the elderly. As the inhabitants of these homes for the aged grow older, they need more medical care than was planned when the homes were built. Because of this the financial costs increase steadily, but at the same time, the government wants to spend less and calls for a "caring society"; a call in which nostalgic overtones cannot be overheard. The policy during the last years has been to stimulate elderly people to live independently, as long as they possibly can. This course has been inspired primarily by the efforts to spend less money. At the same time, the government wants to maintain the level of care, especially health care. "Flexible substitution" (for instance extramural vs. intramural; voluntary vs. professional care) is one of the keywords in this situation, in which the government faces the problem of retreat from a situation which it has largely produced itself, but cannot any more sustain. So the expansion of the welfare state turned out to be a trap for the state too, as it could not bear the financial burden that developed during its period of expansion. Social policy regarding the aged in the Netherlands faces the complicated problem of adapting existing institutions to changing needs, improving the quality of the cooperation between the different institutions and clarifying the different responsibilities, competences and legitimate expectations of the public and the private sphere (WRR 1988). But the most important problem stems from the limits that are inherent in the organization of social structures and processes. Existing forms of solidarity can be destroyed by organizations, but cannot be produced by them. Solidarity can be supported or encouraged by general arrangements, if there is an awareness of this inherent limitation. The Dutch experience is a specific example of a broader cultural process that is connected with the technocratic illusions of the modern Western tradition. Our discussion of some characteristics of this process regarding the organization of intramural care for the elderly has proceeded on a cultural macro-level and on the organizational level. We will now continue our discussion on the level of individual cultural attitudes.
The Cultural Ethos and the Welfare State Adriaansens and Zijderveld (1981) have tried to develop a theory concerning the "selective affinity" ("Wahlverwandtschaft") between the welfare-state and the dominant ethos of its citizens. The theoretical model for this endeavour is Weber's theory concerning the selective affinity between the "protestant ethic" and the "spirit of capitalism". The characteristics of the "protestant ethic" in Weber's analysis, resemble Zijderveld's "moralist" ethos, as contrasted with an earlier "amoral" and a later "immoralist" ethos. These constructions have to be understood as ideal types in the Weberian sense. Zijderveld aims at a sociological understanding of the cultural changes that took place in the subsequent
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process of, first, the pillarized expansion of the welfare state; followed by depiUarization through general financial support and control by the state; and finally the contraction of the welfare state. The pillarized organizations, the vehicles of active modernization, show according to this theory, a "moralist ethos", characterized by optimism regarding the progressive construction of reality; the willingness to be active in service of the own pillar-community and to be led by strong leaders that represent traditionally accepted values. The ethos of the traditional pillars represents the values of responsibility, active life, achievement and progress. The mutual affinity between the welfare state and the "immoralist" ethos would - according to Zijderveld - be characteristic for the stage of modernization that sets in when the welfare state starts to embrace society. At this point the theory is linked to the international debate on the welfare state. Typical for the "immoralist" ethos is a "consumerism" (Janowitz 1976); a dependency of the individual in relation to the arrangements of the welfare state and a calculating opportunistic awareness of one's own rights and interests. Christopher Lasch (1979) has labelled this attitude "narcissistic". The social structures and relationships that are supposed to go together with this "immoralist ethos" give the impression of shortlived and changing contacts, with little continuity and intensity of involvement. The ideal typical construction of the immoralist ethos does have some selective affinity with the arrangements of the welfare state. But it is also important to make some distinctions concerning the range of the concepts. As for the historical developments, it should be kept in mind that processes like depillarization, expansion and contraction of the welfare state show a different momentum in different segments of society. It has already been pointed out that in some areas of intramural care the general process of depillarization lags behind. Different segments of Dutch society show a different pattern and a different rate of development. Also we may see indications of a moralist and immoralist ethos in the same society. Moreover, it is necessary to relate the different ideal types of the dominating ethos to different spheres of life, such as politics, religion, personal relationships and personal attitude towards life. In one sphere the same person may show a different ethos from the one that is shown in another sphere (Halman a.o. 1987). Finally it is important to point to differences between rural and urban situations. Most literature on problems of social policy concentrates on the problems in the big cities in the western part of the Netherlands. In rural areas, sometimes at tittle distance from the big city, the situation regarding mutual solidarity, family-care and social-cultural ethos may be different. So the "immoralist ethos" is not as general as to be representative of the whole society, but can be seen, in a changing and pluriform constellation, wherever the welfare state through its provisions stimulates the consumerism attitude, or frustrates it by withdrawal of provisions. The immoralist, consumerism ethos could flourish especially where the
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process of de-pillarization left a void regarding principles and values. This situation in the Netherlands is a characteristic example of a broader cultural process in Western Europe that is, for instance, reflected in the philosophical discussion between the "modernists" and the "post-modernists" concerning the meaning of the modem European tradition (Featherstone, 1988). Moreover, the cultural problem of aging and the definition of somebody as "elderly" clearly transcends national frontiers. Towards a Post-Bureaucratic Solidarity
The negative effects of the welfare state have been noticed internationally and also in the Netherlands criticism has been inspired by the works of Illich (1975), Foucault (1979), Habermas (1988) and other thinkers. One of the main points of criticism is that the way in which the welfare state tried to compensate, protect and help, has become a repressive force of its own. The controlling activities of the statistical databanks that were developed during the expansion of the welfare state did not diminish when the financial resources of the welfare state shrank. On the contrary: to be able to get a firmer grip of expenses and their specific uses, control has been intensified. To put it bluntly: to get less money, more forms have to be filled out. Professional care, bureaucratic organization, data banks and regulations are not neutral, but form an important new influence in modern society. Every existing human being is registered and obliged to go to Kindergarten at the age of four, at six to elementary school, obliged to attend school until a certain age; some years later permitted to vote, drive a car, get married, start a business etc. The gradual unfolding of fights and opportunities around the age of 18, is 40-50 years later followed by restrictions: not being allowed to work anymore, not being allowed to be placed on a ballot, but entitled to a pension as a compensation. This institutionalization of the lifecourse (Kohli 1985) could be interpreted in the spirit of Foucault as a monitored panopticum in which we live and are observed constantly. Because of the central regisgation of all people, the exact age an be known at all times and nobody will be forgotten when he enters suddenly, endowed with an unescapable birthday-present, into the next programmed stage of his life. The bureaucratic regulation of the life course has a strong effect on the fives of many elderly, as they are suddenly forced to abandon their working fife. Socially produced tensions like these may well affect the health of the excluded elderly. Research in this field though, is exlremely complicated because of the multi-causality that is involved. And moreover, in the Netherlands, this type of research lags behind dramatically, compared with research in other countries (cf. WRR 1987). The welfare state tried to realize a societal solidarity based on the fiches produced by the growing economy and working by means of advanced bureaucratic planning. It turned out that not only are the costs too high, but that
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money cannot buy the personal care and affective attention that were often realized in the traditional forms of solidarity. On the other hand, these traditional forms also had their repressive side. We can think for instance of the obligation of daughters to look after their needy parents and we can think of the fixed and restrictive definitions of roles (also those of elderly people) that are often inherent in traditional patterns. Moreover elderly people were often financially completely dependent on their family, if they had any. Regarding such traditional restrictions we can only hope that the project that inspired European Modernity" freeing mankind from need and domination, shall be continued. But that has to be done in awareness of the repressive potential of organized arrangements that are supposed to work in the interest of the people. This last uncritical presupposition that has been exposed in recent developments, has been typical of the expanding welfare state, also in the Netherlands. In this country maybe even a little bit more than in other countries. In the foregoing we have tried to explain some characteristics of the organized care for the elderly in the Netherlands, from peculiar cultural processes concerning the pillarized expansion of the welfare state. Compared with other countries, the Netherlands may have more difficulty in organizing care for the elderly on the basis of voluntary associations because of the creation of the "horizontal void". On the other hand, this weakness of traditional patterns doesn't have to be disadvantageous, if people would succeed in developing new forms of solidarity that are not based on traditional authorities, professional care or bureaucratic regulations, but on mutual involvement. The emerging half spontaneous, half organized forms of solidarity, developing in answer to practical problems of elderly people are experimental grounds for such a needed new solidarity in which modern technical developments are not idealized, but used as practical means, serving the fulfillment of human needs. ACKNOWLEDGEMENT The authors wish to thank Dr. D. Th. Kuiper for his comments on an earlier version of this article.
Vrije Universiteit Amsterdam * Note added in Proof. In a strict sense a pillar was a religiously integrated social block, penetrating the diverse spheres of social life and embracing different socio-economic classes and strata. In reality there were tensions and fractions within each pillar, especially those resulting from the different social classes. As the denominational groups succeeded in forming their Roman Catholic and Protestant pillars, the Socialists and conservative Liberals were more or less forced into a pillarized structure and developed pillar-like organizations of their own. Whereas the denominational pillars were composed of all socio-economic classes, the differences between the Socialists and the conservative Liberals corresponded more directly with the socio-economie tensions between the classes and strata that they were composed of. The interpretation of the historical and
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societal significance of the pillars differs, according to the different positions of authors regarding the conceptualization of ideological and structural factors. This is shown in an ongoing and extensive debate that cannot be dealt with here (Goudsblom 1967, Lijphart 1968, Stuurman 1983). REFERENCES Adriaansens, H. P. M. & A .C. Zijderveld, "Vrijwillig Initiatief en de Verzorgingsstaat", Deventer 1981. Bartlema, J., Knipscheer, C. P. M. and Poppel, Ft. van, Mantelzorg en bet Toekomstige Verwantschapsnetwerk; Enige Empirische Indicaties, in Verslagboek Ned. Congres voor Gerontologie, 1987. C.B.S., Statistiek van de Bejaardenoorden, 1965, 1970, 1975, 1980, 1984, 's-Gravenhage/I-Ieerlen. C.B.S., Statistisch Zakboek 1987, Heerlen. Collot, C., et. al. 1982 Toward an Improvement in Self-Reliance of the Elderly; Innovation + New Guidelines for the Future. Cleirppa, Paris. Commission of the European Communities, The Economic Implications of Demographic Change in the European Community, Brussels 1978. Doom, J. van. Welfare State and Welfare Society: The Dutch Experience. The Netherlands Journal of Sociology 1978. Featherstone, M. (Ed.) Postmodemism. London 1988. Foucault, M., "Discipline and Punish", New York 1979. Goudsblom, J. "Dutch Society", New York 1967. Guillemard, A. M. Old Age and the Welfare State. London 1983. Habermas, J. The Theory of Communicative Action. Cambridge 1987. Habermas, J. The New Obscurity: The Crisis of the Welfare State and the Exhaustion of Utopian Energies. Philosophy & Social Criticism 1986. Halman, L. et al. Traditie, Secularisatie en Individualiscring. Tilburg 1987. Have, H. ten, "Het Verpleeghuis: Veld van Onderzoek", Deventer 1979. Heek, F. van, "Het Geboorteniveau der Nederlandse Rooms-Katholieken", 1954. Heuvel, W. J. A. van den, "Aanpassing in Verpleeghuizen", Nijmegen 1973. Illich, I. Medical Nemesis. New York 1975. Janowitz, M. Social Control of the Welfare State. New York 1976. Kohli, M., "Die Institutionalisierung des Lebenslaufs", K61ner Zeitschrift ffir Soziologie and Sozialpsychologie 1985. Lasch, C., "The culture of narcissism", New York 1979. Lijphart, A., 1968. The politics of accommodation. Pluralism and democracy in the Netherlands. Berkeley: University of California Press. Ministerie van Sociale Zaken en Volksgezondheid. Overzichtgegevens Verpleegtehuizen, VAR-reeks, jaargang 1969, no. 10, 's-Gravenhage. Ministerie van Volksgezondheid en Milieuhygi~ne, VAR-reeks, jaargang 1974, 'sGravenhage. Stuurman, S. Verzuiling, kapitalisme en patriarchaat. Nijmegen 1983. Wilansky, H. L., "The Welfare State and Equality", Berkeley 1975. Wetenschappelijke Raad Regeringsbeleid "De Ongelijke Verdeling van Gezondheid", Den Haag 1987. Wetenschappelijke Raad Regeringsbeleid "Ordening en Sturing in de Ouderenzorg", Den Haag 1988.
AGEING IN THE NETHERLANDS: STRUCTURAL
AND CULTURAL CHARACTERISTICS
ABSTRACT. This article discusses the specific situation of social policy for the elderly in the Netherlands. On the one hand, due to a prolonged high birth rate after the Second World War, the proportion of the aged is relatively moderate in comparison with surrounding countries. On the other hand, more aged people live in intramural institutions than in other ¢ountrles, which contrasts with the availability of informal care, resulting from the relatively large proportion of younger persons. Some possible explanations for this paradoxical situation are explored, especially the competition between the different social "pillars" in Dutch society during the expansion of the welfare state. Key Words: demographic developments, social policy for the aged, welfare state, social pillarlzatlon.
INTRODUCTION For a number of years there has been a growing awareness of the very specific situation in the Netherlands with regard to social policy. Since the sixties, the Dutch welfare state has achieved one of the highest levels o f welfare in the world. The public social insurance system provides an income at the minimum standard o f living for all residents; there is a highly developed health care system and a special health insurance system for all the disabled, old as well as young. O f course, also in the Netherlands, these arrangements have been threatened lately by the financial problems of the government. Within this context, policy for the elderly seems to be a special case. In the next section (A), a statistically based picture will be presented o f the ageing of the population in the Netherlands and of the policy for the elderly as developed over the last decades. Special attention will be given to the growth of professional care for the frail elderly in relation to the availability o f informal care for them. The interrelationship between both seems to be paradoxical in the Dutch situation. Subsequently, in section (B), we will explore several explanations for this paradoxical situation. A. The Paradox: Ageing, the Family and Services f o r the Elderly. Ageing can be studied at the level o f the family, at the level o f organized institutions and at the level o f society. Each has its special focus, but each of them is interrelated and has to be kept in mind to develop a balanced picture. It is the intention o f this section to develop such a picture with special attention to Journal of Cross-Cuhural Gerontology 4: 129-142, 1989. © 1989 Kluwer Academic Publishers. Printed in the Netherlands.
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the amount of institutional services developed for the elderly and the availability of family members to care for the elderly. The first step is to show that the Netherlands have, in comparison with many other Western European countries, a low percentage of people of 65 and over. The figures in Table I show the difference. Most countries hover around 13 or 14% elderly, while the Netherlands is the lowest of the presented countries with 10.7% in 1975. This low percentage of elderly is related to the general TABLE I The growth in the percentage of people above 64 years of age in some Western European countries
West Germany France Italy Netherlands Belgium United Kingdom Denmark Luxembourg
1975
1990
2005
14.3 13.3 12.0 10.7 13.9 14.0 13.2 13.0
14.5 12.7 13.5 12.3 13.0 14.8 14.7 12.9
17.1 13.8 15.2 13.3 13.7 13.9 13.7 15.3
Source: Commission of the European Communities. The
economic implications of demographic change in the European Community, Brussels, 1978. demographic composition of the Dutch population. Because of a very high birth rate up to the end of the sixties, the relative size of the older cohorts is small. The Netherlands has one of the highest birthrates up to the end of the 1960s. (Bevolkingsstatistiek EG, 1982.) This implies - and this is our second point that on average, the families in the Netherlands are bigger in comparison with other Western European countries. In the last decades, older people in the Netherlands had more family members available for support than in other countries and this will be the same for the next decades. This means, for example, that for the elderly in the year 2000 a relatively large number of children between 40 and 60 will be available to care for their older impaired parents. It has been demonstrated that caregiving for older parents by adult children is, in accordance with the traditional division of labor between the sexes, in the large majority (95%) of cases still a task for daughters. We do not imply that this situation is normal, nor that it must necessarily be continued. Should this pattern be continued, however, then the availability of daughters remains relevant. In Table II, the findings of a prospective study are summarized, showing how after 2010 the drop in the birthrate of the seventies will result on the average, in a considerably lower number of daughters available to care for older women.
AGEINGIN THE NETHERLANDS
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TABLE II Average number of expected daughters in The Netherlands of women 50, 60 and 70 years of age frum nine cohorts beginning in 1910 years
cohort
1980
1910 1915 1920 1925 1930 1935 1940 1945 1950
1.28
1985
1990
1995
2000
2005
2010
2015 2020
1.31 1.31
1.29 1.25
1.25
1.24 1.24
1.16
1.23 1.16
1.03
1.15 1.03
0.93
1.02 0.93
0.86
0.92 0.86
0.85
Source: Bartlema, Knipscheer, Poppel van (forthcoming). The availability of adult children to care for their parents is not only dependent on the number of children, but also on their involvement in other activities. One of the main activities which may prevent adult daughters from taking care of their impaired parents is their participation in the labour force. In general, this participation has increased since the second World War in all Western European countries, but not at the same rate. The Netherlands are, astonishingly enough, one of the countries in Europe with the lowest proportion of women in the labour force. Of those women between 45 and 60 years old, no more than about 24% are active in the labour force. In France, the United Kingdom and Denmark, this participation is up to 60 or 70%. The Netherlands' lower proportion of elderly, larger families and more time available among the daughters of older people, means that in the last decades the Netherlands had, on the average, more informal caregivers for impaired older people available than most other Western European countries. Given this situation, it is the more remarkable that (in the same period) the number of old people in institutions has grown disproportionately in comparison with other Western European countries. Collot et al. (1982) presented percentages of older people age 65 and over in communal accommodations (excluding hospitals) in several European countries: Belgium 5%, Denmark 7,9%, France 5%, Greece 1%, Ireland 3,6%, Luxembourg 4,7%, Fed. Rep. of Germany 4,5% and United Kingdom 5%. Comparing these percentages with those for the Netherlands presented in Table III reveals the high proportion of older people in the Netherlands in intramural care, in a home for the aged or a nursing home, over the fast few decades. A home for the aged is a collective housing facility for older people who have some Irouble with maintaining an independent household. When these people
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TABLE IH Number and proportions of older people in The Netherlands living in institutional settings
1965 1970 1975 1980 1984
homes for the ageda
nursing homes
69.431 105.161 131.993 133/323 132.562
9.318b 17.312e 33.958 d 39.456 e 40.433 f
5,7% 7,8% 8,9% 8,1% 7,7%
0,80% 1,30% 2,27% 2,40% 2,33%
" Statistiek van de Bejaardenoorden 1965, 1970, 1975, 1980 en 1984, CBS, 's-Gravenhage/I-Ieerlen. 1, Overzicht gegevens verpleegtehuizen in Nederland. VAR-reeks, jaargang 1969, no. 10, Uitg. Ministerie van Sociale Zaken en Volksgezondheid. c VAR-reeks jaargang 1974, no. 8, Uitg. Ministerie van Volksgezondheid en MilieuhygiSne. d Statistisch Zakboek 1987, CBS, Heerlen. apply for a place in a home for the aged and are admitted, they get a private room and full service in household affairs (cooking, cleaning) and sometimes some personal care (washing, bathing, clothing), but no daily nursing care. However, the government no longer builds new homes for the aged, and the "full service" provision in existing homes for the aged has been changed to "needed service". Those who need nursing care because of chronic conditions now go to a nursing home. Over the years a distinction has grown up between somatic nursing homes and psychogeriatric nursing homes. Somatic nursing homes offer, in addition to the services for chronic patients, rehabilitation programs for those who are recovering from strokes and accidents. Rehabilitation patients live temporarily in a nursing home, about 20% of the beds in nursing homes being occupied by them. How can we understand this high proportion of elderly in institutions in the Netherlands? Did the Dutch family shirk its responsibility for the older family members? Has the Dutch government promoted such a high standard of institutional care facilities that it seems to be attractive to live in them? Or is there a lack of professional home help and home care? This last suggestion may be explored based on some comparative data. Table IV presents some figures on the availability of professional home help and home care for the elderly in some European countries. The Netherlands appears to be well developed in this area of services for the elderly too. Dutch care for the elderly, therefore, indicates - more implicit than explicit a trust in institutional professional care. Since the Second World War institutional care was promoted, and only recently, because of lack of money as well as because of changing views concerning institutional care, was a more restrictive policy implemented. The next section of this paper will explore some cultural explanations for this
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TABLE IV The availability of professional home services for older people in some countries in percentages.
getting home help getting home nursing sheltered housing hospital beds per 100 65+
England
Scotland
9.0 17.7 6.0 2.0
7.7 12.9 2.6 2.0
Norway Israel 6.2
2.5 10.0 1.7
3.9
Netherlands 10.0(1976) 9.7
Source: International Social Security Association, long-term social care and social security, 1984.
situation. The focus of the explanations will be on the Dutch civilization and its connections with the development of the Dutch welfare state over the last decades. B. Towards an Explanation of the Paradox: Cultural Developments in the Netherlands
At first sight it may not be clear how cultural factors could help explain the paradoxical situation in the Netherlands. The amount and quality of the service for the elderly seem to be directly affected by the turbulent developments concerning the fate of the welfare state. Not only the political initiation and expansion, but also the later crisis, of this compromise of social-democratic and capitalist orientation show an international synchrony (Guillemard 1983), which points to the macro-economic processes that made the welfare state possible and also caused its decline. This synchrony corroborates Wilensky's thesis, that not ideological or cultural factors, but the rate of economic growth, determined the development of the welfare state and also, it may be added, its decline (Wilensky 1975). The institutional arrangements of the welfare state differed, of course, nationally, depending on the cultural traditions involved and these still partly shape the problems that have to be dealt with when the arrangements of the welfare state decline. In this perspective, we want to pay attention to the typical Dutch constellation of "pillarization". Pillarization
The typical, though not exclusive Dutch phenomenon of pillarization consisted of four competing social blocks that were clearly separated from each other and internally vertically controlled.* * See Note Added in Proof on p. 141.
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JAN BAARSAND KEES KNIPSCHEER
The four pillars, a Roman Catholic, a Protestant, a Socialist and a Liberal one, tried to imprint their specific character on all spheres of social life. Not only would people (especially from the competing denominational blocks) not marry someone from another pillar, but they would also have their own schools, newspapers, libraries, read their own newspaper, be a member of their own radio & TV-organization, vote for their pillar-leaders, buy books from their own pillar-publishers in their own book-shops and would also, of course, organize the care for the elderly on their own pillarized basis. In the southern part of the Netherlands, where the majority of the population traditionally belonged to the Roman Catholic Church, the pillarized structure was (and to a large extent still is) in a homogeneous way, present in many spheres of life. In other parts of the Netherlands however, the national pillarization manifested itself at the local level. In a larger village there would be Roman Catholic, Protestant and General football-clubs, schools, libraries, etc. People would buy from their fellow greengrocer and the Protestants would even be very sensitive regarding the differences between denominational subcultures within their own pillar. The impulse for the creation of the pillars came from the denominational groups, who had different political aims, ranging from an emancipation from their minority position to a religious neutralization of the socialist movement. In their energetic struggle they shared the first objective: organizing elementary schools on a denominational ("special") basis. As a result of these efforts, in 1945 70% of the elementary schools were organized on a special (Roman Catholic or Protestant) basis, whereas in 1890 this was the case for only 20% (Van Doom 1978). The struggle for "special" education extended to universitylevel (a Protestant university was founded in 1880 in Amsterdam, a Roman Catholic university in 1923 in Nijmegen), where even a Protestant and a Roman Catholic philosophy of science guided the efforts in education and research. The struggle for emancipation manifested itself also in a strong encouragement of a high birth-rate, especially in Roman Catholic families (Van Heek 1954), supported by the general allowances for children since 1939. This policy had especially strong results after the second worldwar. Besides school-education, the denominational pillars were especially active in those social areas that were more or less a direct continuation of the traditional charity of the church. And in spite of the later de-pillarization, the denominational organization is still - at least formally - dominant in institutional care for the physically or mentally handicapped and for the impaired elderly. Ideologically, the pillarized policies were legitimized by the Roman Catholic principle of "subsidiarity", and by the Protestant principle of "sovereignty in one's own sphere". The principle of subsidiarity meant that affairs that are settled at a lower level are not to be re-examined at a higher level. This principle was also meant for affairs within the pillar itself (notwithstanding the fact that clerical hierarchy ruled supremely), but functioned primarily as a way to protect the pillar from intervention by the national government or by other pillars. Also
AGEINGIN THE NETHERLANDS
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this principle implied that the state should only be active where and as long as private initiatives had not been developed, and that the state should withdraw as soon as this was the case. The Protestant principle of sphere-sovereignty had an analogous meaning. It follows, therefore, that the Socialists and the Liberals were not the active parties in the process of pillarization. The Socialists were, of course, much more inclined to encourage state-activities, but nevertheless developed their own pillar-like forms, insofar as they wanted to distinguish themselves from the other pillars and from the ruling capitalist state. The Liberals, to the contrary, would support this capitalist state, but were inclined to restrict its activities. Socialists and Liberals were more or less forced into the pillarized structure and found themselves often together (for instance in the case for general schools), in their opposition against the denominational pillars. The pillarized social structure became the national vehicle of emancipation and internal integration, flavored by a strong Dutch tradition of moralization, which was shared not only by the Catholic and Protestant pillars but also by the Socialists and (maybe a little less) by the Liberals.
Pacification and Cooperation The four pillars, though, had to acknowledge each other's existence and had to face the reality of not being able to make the whole country into a Protestant, Liberal, Roman Catholic or Socialist nation. At the top of the pillars, the mutual leaders developed a solid consensus about the national political aims after the Second World War. These were, first economic reconstruction and industrialization, and after that, the development of the welfare state, coordinated by the 1952 inaugurated "Department for Social Work" (Ministerie voor Maatschappelijk Werk). The pillars cleverly let the state finance the activities that were controlled by their own organizations. Especially after 1950, the welfare state grew at an increasing rate through the pillarized institutions that competed with each other at the state's expense. Moreover, the institutionalized rule of "three of TABLE V Denominational orientation of homes for the aged in The Netherlands in 1987a Catholic oriented (KvB) Protestant oriented (PVIB) Humanist oriented (HSHB) Public/general (AIVB) Not known
587 457 41 403 62 1550
a Based on personal information.
37,8% 29,5% 2,6% 26,0% 4,0% 100%
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IAN BAARSAND KEESKNIPSCHEER
each" implied that there should be a Roman Catholic, Protestant and General version of each subsidized institution. Some information on the denominational distribution of the homes for the aged in the Netherlands is given in Table V. The opportunistic policy of the pillar-elite was in a way a foreshadowing of the "immoralist ethos" that is often supposed to be related to the welfare state and which will be discussed later. Once the rate of economic growth enabled the expansion of the welfare state, the pillars were able to organize in a relatively short time and on a national scale, the arrangements that they thought were necessary. Also the institutions of intramural care for the elderly could be organized quickly, drawing on the potential for leadership and professions that was present in the pillars. The Horizontal Void
Inherent in the pillars was a strong hierarchic structure of leadership. The principles of subsidiarity and sphere-sovereignty functioned especially (as has been stated above) to protect the pillar from external interference. It did not mean that each level of the pillar had the right to make its own decisions. Above all there was the strong leadership of the bishops or other denominational boards of management, represented at every level by the priests or the reverends and their wives, who were honored guests and leaders at most public activities. Apart from this organized presence of the leading clergy at every level, there was a strongly internalized obedience towards the church and its leaders, complemented by social control. As a consequence, caregiving tended to be vertically organized, led firmly and centrally. The pillarized "top down"-organization left little space for horizontal community-care. Therefore we cannot find in the Netherlands large voluntary organizations such as the British Age Concern or the Abbeyfield Society. And, also, in families the responsibility was dictated and shaped by the clergy to such an extent that a tradition of care that was independent from religious doctrine had difficulty in developing. But during the sixties the process of secularization manifested itself clearly in the political composition of the Netherlands. The two denominational pillars that held a solid marjority after the Second World War until the elections of 1967, have received since the early seventies only a third of the votes. As a result of the created horizontal void, the secularization and the ensuing rebellion against the church and its paternalistic organizations, the structures of communal life and family have been affected to such an extent, that some observers have spoken of an "immoralist" ethos. The opportunistic strategy of the pillar elites thus turned out to be a trap. It turned against the strategists as the state gradually gained more control of the activities that it financed. The outcome, generally speaking, being that the institutions that were once seen as the embodiment of the specific emancipationary movement lost their internal traditional force.
AGEINGIN THENETHERLANDS
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The result of the absorption of the piUarized institutions by the expandin~ welfare state is the return - in a historically changed setting - of the individualistic society that the denominational and socialist pillars had set out to fight. This not only can be seen in the traditionally Christian institutions under the influence of the broader process of secularization that takes place in Western culture, but also in the socialist movement. The social democratic policy of creating a socialist nation in the form of a welfare state has emptied the socialist inspiration and has focused political attention on fighting for the privilege of governmental finance. The organizations of politically active elderly have had very little influence on social policy in the Netherlands. Here also the organizations developed within the patriarchal pillars and were dominated by them. The pillarized elderly-organizations, the Roman Catholic "Unie KBO", the Protestant "PCOB" and the general "ANBO" traditionally had great difficulty in cooperating because of the profound differences that were thought to exist between them. For several years, though, these organizations have been united in the COSBO and it is to be expected that the elderly will be more active and will have more influence through this organization in the years to come. Maybe even more important are the rapidly growing number of initiatives of elderly people concerning the self organization of their situation.
Institutional Developments in Social Policy Regarding the Elderly In addition to the foregoing, several additional factors have influenced the relative high percentage of elderly people living in institutions for intramural care. First, since the fifties we can observe an increasing tendency to leave the shared household of the multigenerational family, where that still existed. The allowances for the elderly made them less dependent on their family and enabled and encouraged them to live separately. On the other hand, children tended to marry young and, because of the expanding economy, were able to support their own household. This resulted in the long sustained high birthrate and the increased tendency to live in separate households after the second world war. In turn, in the densely populated Netherlands, this created a shortage of houses, which the government tried to relieve by building large homes for the aged. The expansive strategy of the pillars in the area of social care harmonized with this policy to relieve the housing problems. Later evaluations showed that this policy had various detrimental effects. The publications by Van den Heuvel (1973) and Ten Have (1979) indicate growing doubts about the former idealization of institutional housing of the elderly to meet various categories of need. Socially, there was the strong disadvantage of isolating elderly people t~om younger people; moreover, once the home for the aged has been entered, it turns out to be difficult to leave it, to start to live independently again. Gradually, as the inhabitants grew older and relatively few younger ones
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JANBAARSANDKEESKNIPSCHEER
entered the homes, the atmosphere in the homes for the aged changed. The physical fitness and growing self-confidence of the "new old" contrast more and more with the character of the intramural settings for the elderly. As the inhabitants of these homes for the aged grow older, they need more medical care than was planned when the homes were built. Because of this the financial costs increase steadily, but at the same time, the government wants to spend less and calls for a "caring society"; a call in which nostalgic overtones cannot be overheard. The policy during the last years has been to stimulate elderly people to live independently, as long as they possibly can. This course has been inspired primarily by the efforts to spend less money. At the same time, the government wants to maintain the level of care, especially health care. "Flexible substitution" (for instance extramural vs. intramural; voluntary vs. professional care) is one of the keywords in this situation, in which the government faces the problem of retreat from a situation which it has largely produced itself, but cannot any more sustain. So the expansion of the welfare state turned out to be a trap for the state too, as it could not bear the financial burden that developed during its period of expansion. Social policy regarding the aged in the Netherlands faces the complicated problem of adapting existing institutions to changing needs, improving the quality of the cooperation between the different institutions and clarifying the different responsibilities, competences and legitimate expectations of the public and the private sphere (WRR 1988). But the most important problem stems from the limits that are inherent in the organization of social structures and processes. Existing forms of solidarity can be destroyed by organizations, but cannot be produced by them. Solidarity can be supported or encouraged by general arrangements, if there is an awareness of this inherent limitation. The Dutch experience is a specific example of a broader cultural process that is connected with the technocratic illusions of the modern Western tradition. Our discussion of some characteristics of this process regarding the organization of intramural care for the elderly has proceeded on a cultural macro-level and on the organizational level. We will now continue our discussion on the level of individual cultural attitudes.
The Cultural Ethos and the Welfare State Adriaansens and Zijderveld (1981) have tried to develop a theory concerning the "selective affinity" ("Wahlverwandtschaft") between the welfare-state and the dominant ethos of its citizens. The theoretical model for this endeavour is Weber's theory concerning the selective affinity between the "protestant ethic" and the "spirit of capitalism". The characteristics of the "protestant ethic" in Weber's analysis, resemble Zijderveld's "moralist" ethos, as contrasted with an earlier "amoral" and a later "immoralist" ethos. These constructions have to be understood as ideal types in the Weberian sense. Zijderveld aims at a sociological understanding of the cultural changes that took place in the subsequent
AGEING IN THE NETHERLANDS
139
process of, first, the pillarized expansion of the welfare state; followed by depiUarization through general financial support and control by the state; and finally the contraction of the welfare state. The pillarized organizations, the vehicles of active modernization, show according to this theory, a "moralist ethos", characterized by optimism regarding the progressive construction of reality; the willingness to be active in service of the own pillar-community and to be led by strong leaders that represent traditionally accepted values. The ethos of the traditional pillars represents the values of responsibility, active life, achievement and progress. The mutual affinity between the welfare state and the "immoralist" ethos would - according to Zijderveld - be characteristic for the stage of modernization that sets in when the welfare state starts to embrace society. At this point the theory is linked to the international debate on the welfare state. Typical for the "immoralist" ethos is a "consumerism" (Janowitz 1976); a dependency of the individual in relation to the arrangements of the welfare state and a calculating opportunistic awareness of one's own rights and interests. Christopher Lasch (1979) has labelled this attitude "narcissistic". The social structures and relationships that are supposed to go together with this "immoralist ethos" give the impression of shortlived and changing contacts, with little continuity and intensity of involvement. The ideal typical construction of the immoralist ethos does have some selective affinity with the arrangements of the welfare state. But it is also important to make some distinctions concerning the range of the concepts. As for the historical developments, it should be kept in mind that processes like depillarization, expansion and contraction of the welfare state show a different momentum in different segments of society. It has already been pointed out that in some areas of intramural care the general process of depillarization lags behind. Different segments of Dutch society show a different pattern and a different rate of development. Also we may see indications of a moralist and immoralist ethos in the same society. Moreover, it is necessary to relate the different ideal types of the dominating ethos to different spheres of life, such as politics, religion, personal relationships and personal attitude towards life. In one sphere the same person may show a different ethos from the one that is shown in another sphere (Halman a.o. 1987). Finally it is important to point to differences between rural and urban situations. Most literature on problems of social policy concentrates on the problems in the big cities in the western part of the Netherlands. In rural areas, sometimes at tittle distance from the big city, the situation regarding mutual solidarity, family-care and social-cultural ethos may be different. So the "immoralist ethos" is not as general as to be representative of the whole society, but can be seen, in a changing and pluriform constellation, wherever the welfare state through its provisions stimulates the consumerism attitude, or frustrates it by withdrawal of provisions. The immoralist, consumerism ethos could flourish especially where the
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JAN BAARSAND KEESKNIPSCHEER
process of de-pillarization left a void regarding principles and values. This situation in the Netherlands is a characteristic example of a broader cultural process in Western Europe that is, for instance, reflected in the philosophical discussion between the "modernists" and the "post-modernists" concerning the meaning of the modem European tradition (Featherstone, 1988). Moreover, the cultural problem of aging and the definition of somebody as "elderly" clearly transcends national frontiers. Towards a Post-Bureaucratic Solidarity
The negative effects of the welfare state have been noticed internationally and also in the Netherlands criticism has been inspired by the works of Illich (1975), Foucault (1979), Habermas (1988) and other thinkers. One of the main points of criticism is that the way in which the welfare state tried to compensate, protect and help, has become a repressive force of its own. The controlling activities of the statistical databanks that were developed during the expansion of the welfare state did not diminish when the financial resources of the welfare state shrank. On the contrary: to be able to get a firmer grip of expenses and their specific uses, control has been intensified. To put it bluntly: to get less money, more forms have to be filled out. Professional care, bureaucratic organization, data banks and regulations are not neutral, but form an important new influence in modern society. Every existing human being is registered and obliged to go to Kindergarten at the age of four, at six to elementary school, obliged to attend school until a certain age; some years later permitted to vote, drive a car, get married, start a business etc. The gradual unfolding of fights and opportunities around the age of 18, is 40-50 years later followed by restrictions: not being allowed to work anymore, not being allowed to be placed on a ballot, but entitled to a pension as a compensation. This institutionalization of the lifecourse (Kohli 1985) could be interpreted in the spirit of Foucault as a monitored panopticum in which we live and are observed constantly. Because of the central regisgation of all people, the exact age an be known at all times and nobody will be forgotten when he enters suddenly, endowed with an unescapable birthday-present, into the next programmed stage of his life. The bureaucratic regulation of the life course has a strong effect on the fives of many elderly, as they are suddenly forced to abandon their working fife. Socially produced tensions like these may well affect the health of the excluded elderly. Research in this field though, is exlremely complicated because of the multi-causality that is involved. And moreover, in the Netherlands, this type of research lags behind dramatically, compared with research in other countries (cf. WRR 1987). The welfare state tried to realize a societal solidarity based on the fiches produced by the growing economy and working by means of advanced bureaucratic planning. It turned out that not only are the costs too high, but that
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money cannot buy the personal care and affective attention that were often realized in the traditional forms of solidarity. On the other hand, these traditional forms also had their repressive side. We can think for instance of the obligation of daughters to look after their needy parents and we can think of the fixed and restrictive definitions of roles (also those of elderly people) that are often inherent in traditional patterns. Moreover elderly people were often financially completely dependent on their family, if they had any. Regarding such traditional restrictions we can only hope that the project that inspired European Modernity" freeing mankind from need and domination, shall be continued. But that has to be done in awareness of the repressive potential of organized arrangements that are supposed to work in the interest of the people. This last uncritical presupposition that has been exposed in recent developments, has been typical of the expanding welfare state, also in the Netherlands. In this country maybe even a little bit more than in other countries. In the foregoing we have tried to explain some characteristics of the organized care for the elderly in the Netherlands, from peculiar cultural processes concerning the pillarized expansion of the welfare state. Compared with other countries, the Netherlands may have more difficulty in organizing care for the elderly on the basis of voluntary associations because of the creation of the "horizontal void". On the other hand, this weakness of traditional patterns doesn't have to be disadvantageous, if people would succeed in developing new forms of solidarity that are not based on traditional authorities, professional care or bureaucratic regulations, but on mutual involvement. The emerging half spontaneous, half organized forms of solidarity, developing in answer to practical problems of elderly people are experimental grounds for such a needed new solidarity in which modern technical developments are not idealized, but used as practical means, serving the fulfillment of human needs. ACKNOWLEDGEMENT The authors wish to thank Dr. D. Th. Kuiper for his comments on an earlier version of this article.
Vrije Universiteit Amsterdam * Note added in Proof. In a strict sense a pillar was a religiously integrated social block, penetrating the diverse spheres of social life and embracing different socio-economic classes and strata. In reality there were tensions and fractions within each pillar, especially those resulting from the different social classes. As the denominational groups succeeded in forming their Roman Catholic and Protestant pillars, the Socialists and conservative Liberals were more or less forced into a pillarized structure and developed pillar-like organizations of their own. Whereas the denominational pillars were composed of all socio-economic classes, the differences between the Socialists and the conservative Liberals corresponded more directly with the socio-economie tensions between the classes and strata that they were composed of. The interpretation of the historical and
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