G. CLAREWENGER

INTRODUCTION: CULTURE, HEALTH AND SOCIAL POLICY

One of the recognized universals of human ageing is the distinction that all societies make between the independent well old and the dependent frail old (Amoss & Harell 1981). The bases upon which this distinction is made, how it is marked and the behaviours associated with frailty and ill health in old age, however, are cultural and thus demonstrate a range of variation. This issue of the Journal brings together a collection of papers, which describe various aspects of cultural responses to health and illness in old age from the perspective of a specific society. They demonstrate the interaction of cu/lare, economics and social change and the impact of these factors on elderly people. The papers on Nigeria (Peil, Bamisaiye and Ekpenyong); Poland (Synak); The Netherlands (Baars and Knipscheer); Japan (Maeda, Teshima, Sugisawa and Asakura) and Polynesia (Barker) emphasize different aspects of provision for dependent elderly people in the societies they cover. In part, the different emphases reflect the social welfare situation of the countries involved. Peil et al. concentrate on informal support because, apart from limited pension provision, there is no social welfare support for the elderly in Nigeria. Barker analyses the health and functional status of elderly Polynesians, comparing this with the more industrialized United States in the context of service provision. The other authors pay more attention to social policy measures in the countries concerned and look at the interaction of the formal and informal sectors. Despite the wide differences in content (which in turn reflect to some extent cultural differences between the societies involved) it is possible to look at these papers together and to make a range of cross-cultural comparisons which raise some hypotheses for further investigation. The societies covered represent different levels of development and national prosperity. The Netherlands and Japan are modern, industrialized and urbanized countries amongst those with the highest standard of living in the world. Nigeria and Poland, despite their obvious differences still have large rural populations (47% in Poland), with migration between village and town and lower standards of living. Financial constraints in Poland result in under-resourced welfare provision and in Nigeria the absence of a welfare state makes reliance on adult children (or other relatives) the only available option for the frail elderly. The isolated Polynesian island of Nine, with a total population of approximately 2,500, contrasts with all the other countries, being wholly rural and nonindustrialized but with a relatively high standard of living and health care pro~sion. What comes across strikingly in reading these papers are the conseJournal o f Cro~s-Cultural Gerontology 4: 83-88, I989. © 1989 Kluwer Academic Publishers. Printed in the Netherlands.

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quences which the national and personal economic situation and the process of social change have for dependent old people. Social policy, it can be seen, is both influenced by, on the one hand, cultural values and attitudes, and on the other by the economic context. By the same token, shifts in social policy provision contribute to changes in cultural evaluations and behaviour. With exception of Barker's paper, each of the other four papers goes some way to illuminating the dynamics and cyclical nature of social change in provision for elderly people: culture and economic conditions influence provision which influences attitudes and behaviour which influence social policy and so on. Levels of impairment and thus the distinction between the independent and dependent elderly differ between the countries. In the Netherlands, the cultural emphasis on independence and individualism places a high value on recovery and maintaining mobility. Despite this, other factors, discussed in Baars and Knipscheer's paper, have led to a high level of provision of beds in residential institutions. This resulted in people at low levels of impairment entering residential care (although with the demographic ageing of the population this is becoming less common). In Poland, Nigeria and Polynesia there is less emphasis on individualism and more emphasis on the family group but other environmental and cultural pressures encourage the maintenance of physical mobility and the avoidance of role loss which accompanies physical dependence. Cultural differences in the demands of activities of daily living, however, result in higher levels of disability at comparable levels of impairment in some societies. In Japan, on the other hand, the obligation of children to serve their parents makes rehabilitation difficult because parents accept care as part of being old and children feel that asking independence of parents is denying responsibility. This factor coupled with the high incidence of slrokes results in a high level of bedridden elderly people compared with other countries. In all the countries, adult children are concerned for the well-being of elderly parents, and spouses and children are the main source of support. In Poland and Japan filial responsibility is supported by legislation - sanctions in the first and incentives in the latter - and stigma associated with neglect of parents is discussed by the authors on Nigeria, Poland and Japan. The effect of economic pressures on adult children in Nigeria and Poland are described. In Nigeria the ability of children to support parents is affected by widespread migration from rural to urban areas exacerbated by low incomes, poor transport and high levels of illiteracy. However, most children who can, provide financial and material support, which is more common than instrumental support. The paper on Polynesia also mentions high levels of out-migration of younger generations but we are not told that this creates problems for care. Most of the elderly on Niue live with younger generation relatives, however, and the impact of migration appears to be less. The standard of living of islanders generally appears to reinforce care of elders, although the author identifies a need for increased medical support. In Poland, low incomes, resulting in the necessity of women to work, coupled with the small size of flats, hampers the family's ability to care

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for very dependent people. In Japan, despite the fact that most dependent old people are cared for in the family, their suicide rate is high. Life expectancy figures have improved generally (UN, 1985). The paper on Japan emphasizes the impact of social policy on improving life expectancy. In contrast, in Poland life expectancy has decreased in the context of economic and social pressures. Economic conditions thus appear to have direct effects on longevity, but it seems that social provision cannot overcome deprivations experienced earlier in the life-span. The figures from Japan and Poland both demonstrate higher than expected death rates for cohorts of adults who as children experienced the impact of World War II at critical stages of development and similar statistics are reported from Hungary1. This finding raises important questions about national life expectancy figures, suggesting that improvements in standards of living may take several decades to affect greatly increased longevity in the most deprived countries. The contrasting influence of religion is evident from some of the papers. In Poland, Holland and Japan religions values are shown to reinforce family obligations to the elderly. In Poland, the Roman Catholic Church plays an important unifying role in the country and is the major non-familial institution. Receiving help from the Church is not stigmatized as is receiving state aid and is, therefore, preferred by old people. In the Netherlands, in contrast, religious and ideological diversity results in the division of society and the provision of parallel social support for the old. Receiving help in both these contexts, however, is a mark of identity for the old person concerned and thus without the stigma of state aid. Despite some wide differences between the countries described, parallels between them are as common as contrasts and readers will be able to recognize similarities with societies with which they are particularly familiar. In all countries most reliance in old age is on spouses, adult children and children-inlaw or, in their absence, on other close relatives. Expectations of help focus on daughters rather than sons in the European countries, although old people without daughters are likely to receive support from daughters-in-law and sons. In Nigeria and Japan, responsibility for ageing parents falls primarily on sons and thus on daughters-in-law. Authors from both these countries remark on tension between parents and daughters-in-law. (We are not told about differences between daughters and sons in Polynesia.) In Niue shared households with children and grandchildren are common and child-minding is a frequent task for the elderly. In both Nigeria and Poland ageing women are frequently welcomed into families with younger children as a needed source of child-minding and household tasks. Life expectancy in Nigeria, Poland and Polynesia is lower than in the Netherlands and Japan and birth-rates are higher. Shared households in the first instance, therefore, occur earlier when adult children still have minor children at home, while in the second instance parents and adult children are older and grandchildren often already adult. This difference could perhaps be described as truncated vs. extended life cycles.

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The paper by Peil et al. indicates that many Nigerians already say they are old at 50 and Synak discusses a recent downturn in life expectancy in Poland. In Nigeria the importance of living children to provide for one's old age encourages a high birth-rate and the importance of the family role is well described in the paper. A comparable situation exists on Niue. In Poland, the birth-rate is lower but Poles limit the size of their families despite the slxength of the Roman Catholic Church (personal communication Brunon Synak), Poland still has the highest birth-rate in Europe2. The family in Poland is described in Synak's paper as the focus on Polish life and he has described elsewhere (Synak 1988) how post-war problems, and particularly the recent economic crisis, have resulted in the family turning in on itself as a protective unit. In all these societies, in families without other sources of child care, widowed mothers have a role as child-minders in the homes of adult children - typically the son's home in Nigeria and the daughter's home in Poland. In the Netherlands and in Japan, where birthrates are lower, shared residence is more likely to result from dependency of the parent. However, shared residence is uncommon in The Netherlands and the numbers in residential care are high as the paper by Baars and Krtipscheer discusses. Shared households based on anticipated need of the elderly for support but immediate need of the next generation for child care, coupled in Poland, with housing pressure, might suggest, as has been suggested elsewhere (Ramos 1988), that joint households reflect economic pressures rather than preferred patterns of behaviour and that cultural attitudes, which place high value of the responsibility of children for parents and employ negative sanctions against those who do not provide care, reflect adaptations to the absence of alternatives. Where high quality alternatives to family care exist, i.e. formal or residential care, the argument would continue, family care would become the exception. This argument appears to be supported by recent data from Scandinavia (Daatland 1988; Tornstam 1988), which indicate a preference on the part of elderly people for formal care. High standards of provision appear to reduce stigma in these cases and Baars and Knipscheer's paper supports this hypothesis. However, as their paper shows, the sequel to an acceptance of high-quality residential care in the Netherlands has been a shift away from institutional care to independent formal care in the community, suggesting a developmental process of formal provision. The situation in Polynesia (or at least on Nine) is less clear-cut. Extended family households are prevalent but "assembly units" (small sectional dwellings) are made available by the government to make separate living possible for the elderly. No old peoples' homes are available but the importance of economic factors is not self-evident from the discussion. The contrast between the Netherlands and Japan remains. Both countries have a high standard of living and high investments in social policy. In both countries, the majority of married women are not working. But in the Netherlands high proportions of the dependent elderly are in residential care while in

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Japan most live with the younger generation. The Netherlands are over-provided with nursing homes, while Japan is under-provided. This, together with indications from Polynesia, seems to weaken the economic argument for shared households. The strength of Japanese adherence to the Confucian ideal of filial piety has persisted despite GNP and per capita incomes which could afford to provide residential care. Care for the frail elderly, as in much of Western Europe, comes later in the life cycle, when grandchildren are already adult and women freed from child-rearing responsibilities. However, as Maeda et al. note, increased longevity in Japan, together with the increasing participation of new generations of women in the labour force, is leading to rising demands for residential provision. In this instance, the economic possibilities for residential provision for the high proportion of bed-ridden elderly Japanese did not counter the cultural high value placed on filial piety, but other economic and demographic changes are now pushing in that direction. One hypothesis might be that where ageing parents are the responsibility of daughters, as in Holland, men are likely to become f'mancially responsible for ageing mothers-in-law, while in Japan sons are responsible for their own mothers. Jokes in these countries reflect sonin-law and mother-in-law tensions in Western Europe but daughter-inlaw/mother-in-law tensions in Japan. It would be interesting to know if the same joking phenomenon occurs in Nigeria. Social policy made by men, one might speculate, is more likely to see residential care as appropriate for mothers-in-law than for mothers? It is difficult to assess the relationship between cultural expectations and social policy provision in the context of a single country but it becomes even more complex in comparing nations. It has been variously suggested that the willingness of the family to provide, either precludes the need to provide formal care, as many governments will claim; that it is the inevitable response to &'l absence of formal care; or, that provision of formal care will undermine and weaken family care. What is clear is that social policy has its own dynamic fuelled by the economic context, cultural expectations (which are not static) and social change - none of which factors is independent of the others.

Centrefor Social Policy Research and Development, University College of North Wales, Bangor, U.K.

NOTES 1 Personal communication. Dr. Helga Repassy, Karl Marx Economic University, Budapest, Hungary. z In this context, it is interesting to note that Diesenbacher (1988) sees what he calls the generational contract, i.e. the need to rely on children in old age and consequently higher birth-rates, as the main brake on economic development. The papers presented here can be interpreted as supporting this hypothesis as those with higher birth-rates have greater economic irtsecuHties.

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G. CLAREWENGER REFERENCES

Amoss, Pamela T. and Harrell, Stevan (1981). "Introduction: an anthropological perspective on ageing" in Amoss and Harrell (Eds.) Other ways of growing old: anthropologicalperspectives, Stanford, California, Stanford University Press. Daafland, O.D. (1988). "The growing reservation towards family care in Norway: passive adjustment to failing solidarity or active maintenance of family ties?" Paper presented at conference of Polish Gerontology Association, Gdansk, September 21-22. Diesenbacher, H. (1988). "Generation contract, pensions schemes, birth control and economic growth. Can developing countries learn from the experience of the First World". Paper presented at Conference of Polish Gerontology Association, Gdansk, September 21-22. Ramos, Luis (1988). "Family support for elderly people in San Paulo, Brazil". Paper presented to WHO Expert Working Group on Family Support for Elderly People, Mexico City, February, 22-24. Synak, Brunon (1988). "Family Help for the elderly in Poland", paper presented at the International Congress of Anthropological and Ethnological Sciences, Zagreb, 24-31 July. Tomstam, Lars (1988). "Informal Caring of Elderly in Sweden", paper presented to WHO Expert Working Group on Family Support for Elderly People, Mexico City, February 22-24. United Nations (1985). The WorldAgeing Situation: Strategies and Policies, Department of International Economic and Social Affairs, U.N., New York.

Introduction: Culture, health and social policy.

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