As this century draws to a close, nurses will be increasingly concerned with aging populations in developing countries, both for what we can offer as a profession, and what we can learn about alternate approaches to care from other cultures. There are 370 million older people in the Third World, which comprises more than half (58%) of the world's total elderly. The world's older population experiences a net increase of 1.2 million each month.
Of this increase, 80% occurs in Third World nations. Also, as in the West, the growth rate is fastest for the oldest old, those most likely to have chronic diseases and be in need of health services. Contrary to the myth that families in developing countries "take care of their own," changing economics and shifting migration patterns lead to the projection that the provision of long-term care will be an important part of future programming.1
As a volunteer for the Catholic Medical Mission Board, I had the opportunity to work with the elderly at a longterm care facility in an impoverished slum district in Southern India. In this unlikely spot, within a cultural milieu of crushing poverty, low technology, and severely limited resources, a safe and caring home was provided for the elderly. This article will describe this environment.
The St. Thomas Home for the AgedAbandoned is located on the grounds of the Don Bosco Beatitudes Mission, in Madras, a city of six million on the coast of Southern India. Ahistoryofthe development of the Mission and a description of the adjacent community of Vyasarpady will place the home within the context of its present-day sociocultural setting.
History of the Mission
During the 1960s the streets of Madras, capital of the state of Tamil Nadu, were crowded with the homeless. The problem intensified when thousands of Tamils were exported from Burma and returned to their homeland. Refugees arrived by boat, many malnourished, already sick, and with no hope of employment. These unwanted pavement dwellers were moved to what was then the outskirts of the city, to settle in a marshy, inhospitable area called Vyasarpady, formerly used as a dumping ground for cinders.2
In 1965, a Salesian Missionary from Italy, Fr. Orpheus Mantovani, erected a chapel, surrounded it with sheds, and established a rice kitchen and health clinic to address the compelling needs he found in Vyasarpady. The elderly were uniquely at risk, for not only did some arrive in the city alone, but many who did have families were soon abandoned by desperate children in order to save scarce food supplies for the young.2,3
In response to the needs of the elderly, who were literally starving and dying on the streets alone, the St. Thomas Home for the Aged-Abandoned was founded. Citizens were paid a few rupees apiece for each patient they gathered up and brought to the Mission gates. During the early years there were 7 to 8 deaths per day.3
Today the Mission consists of a complex network of social programs including an orphanage for children of lepers, trade schools, a nursery for malnourished infants, and a busy outpatient clinic. A 1,200-student school serves to educate the children from the slums, and nearby is Pope John's Gardens, a leper village affiliated with the Mission.
Steady progress has been made over the years and the lives of many in Vyasarpady have vastly improved. There is virtually no more starvation, fewer people are forced to live on the streets, and tradespeople are gainfully employed with skills they learned at the Mission, to cite a few examples. However, although development programs have increased the availability and distribution of the food supply, the broad problems of unemployment, inadequate housing and sanitation have not been solved.
Alleyways surrounding the Mission were lined with jumbles of thatched huts, many with dirt floors and most without plumbing. In more destitute areas, makeshift lean-tos served as the only shelter, and families slept and cooked on the sidewalks. Neighborhoods were interspersed with fields used for human defecation. Hindu shrines, ornately painted and decorated, could be found on almost every block. A drought was in progress when I was there, and the dusty earth supported little vegetation. Women formed long lines at tanker trucks for water to meet their families' basic needs.
Autorickshaws and lopsided buses shared streets bulging with bullock carts and motorcycles. The air was thick with heat and heavy with the smells of exhaust fumes, jasmine, and dried fish. Small stalls were filled with piles of pale-colored vegetables and sacks of rice.
Vendors sold strong sweet tea and deep fried sweets. The markets were clogged with people shopping, eating, and visiting. Overall, there was a richness and intensity to the chaotic life in Vyasarpady despite the desperation experienced by many of its people.
St. Thomas Home for the Aged-Abandoned
In stark contrast, the Mission's elderly were housed in a sturdy stucco building covered with flowering vines which could be entered through a small , peaceful garden. An office, where nursing supplies were kept, and a wellappointed chapel, divided the wards into separate areas for women and men. Each ward was an open space filled with rows of metal cots and occupied by patients in various states of wellness. No privacy curtains or isolation areas were available.
The tropical heat was tempered, for circulation, by a thatched roof, high ceilings with fans, and stone floors. Security grating covered the IaU windows, and, as is common in the East, there was no screening for insects. Although provisions for hygiene included inside toilets and bathing areas, many residents preferred to bathe outdoors in the sunshine, using the bucket and dipper method. This practice, however, was frowned upon.
Cleanliness was carefully attended to and there was no urine odor as is sometimes found in convalescent settings. Floors were meticulously scrubbed daily with an antiseptic solution. Linen was washed in the traditional Indian method by a Dhobi who soaped and pounded it clean, then spread it out on the ground to dry. As a result of the ongoing drought, linen changes were restricted.
Because of this, as well as the dorm style of living, some patients were bothered with bedbugs. Infested beds were treated with DDT and aired in the sun. Mosquitoes and house flies were at times a problem, especially when frequent power failures prevented fans from stirring the air.
The facility was operated by the Sisters of the Destitute, an order of Nationals from the predominantly Christian state of Kerala, on the West coast of India. Sister Purissima, the Sister Superior, emphasized that their role was primarily one of management. One of the Sisters, a trained nurse, supervised the medication administration and treatments.
Along with a physician who visited daily, she also managed ongoing illnesses. Her role was more independent and the working style with the physician much more collaborative, than that normally seen in the West.
Most of the personal patient care was done by the residents themselves, or by three women called Ayahs, or "servants." In addition, a ward boy, or "manservant," was available for the male patients, as well as to do errands and repair work around the wards. These workers were very dedicated and appreciative for the opportunity to be employed. Their relationships with the residents were characterized by gentle joking, and they gave sensitive, affectionate care.
Of the 77 patients that lived at the home, 40 were women and 37 were men. Birth dates were not known for 10 residents and for the remainder, ages ranged from 60 to 103 years. Two patients, admitted in 1967, had the longest length of stay, with 9.1 years being the average. General weakness due to old age, illness, and homelessness were the most frequently documented reasons for admission. Most of the elderly experienced more than one chronic condition.
Health Problems: Diseases
The residents' health was affected by years of malnutrition, unsanitary living conditions, and inadequate health care. Though the home setting was a vast improvement, communicable disease was still a major issue. Patients encountered seasonal problems with hepatitisA, filariasis, dengue fever, paratyphoid, and malaria.
Dysentery and influenza commonly occurred. Leprosy and tuberculosis are serious health problems in Southern India, particularly among the elderly. Patients discovered with active forms of these diseases were transferred to community facilities for treatment and did not reside at the home.3
Residents had many of the same chronic and degenerative conditions found among the elderly in the West. These included hypertension, osteoarthritis, coronary disease, cardiovascular accidents, and chronic obstructive pulmonary disease. Psychiatric problems included schizophrenia, dementia, chronic alcoholism, and a significant number of behavioral and emotional disturbances.
Patients received multiple medications for their chronic diseases , much as in the West. Treatment for infectious illnesses, including the common cold, included a regimen of vitamins, analgesics, and antibiotics. The rationale was that these already debilitated patients were at great risk for contracting concurrent illnesses and this drug combination offered some measure of protection. It was also common practice to give an antihistamine along with each antibiotic to prevent adverse reactions. The high drug use, in this age group, appeared to predispose the residents to sequelae that could affect their health status.
Conditions requiring diagnostic facilities could be referred to the Government hospital. However, due to other pressing priorities, most illnesses were managed without lab or X-ray studies. Technological interventions such as oxygen therapy, were not available on the wards.
As a group the patients experienced a variety of functional problems. Visual deficits were common, resulting from histories of infection and malnutrition, as well as age-related cataracts. Although one would expect hearing losses in this population group, resources were not available for screening or hearing aids. Edentulous patients had no dentures, but they could adjust the solid portions of the predominantly rice and curry diet to maintain adequate nutrition.
Speech and motor deficits existed as the result of sequelae from cardiovascular accidents. Ambulation was impaired by osteoarthritis, prolonged bed rest, and lower extremity ulcerations from filariasis, a mosquito-borne lymphatic disease. As a result of the sensory losses and impaired mobility, one of the most significant nursing issues was the inability of many of the patients to participate in activities of daily living. This was exacerbated by the lack of rehabilitation services and limited supplies of adaptive equipment.
Other nursing problems such as urinary incontinence and decubitus ulcers existed in the frail immobile elderly. Interventions paralleled the present-day thinking in the West. For example, care for incontinence included frequently changed draw sheets, sponge baths, and applications of powder to affected skin areas. Indwelling catheters were not used, based on the resulting infections when this had been the practice.3-5
Effects of Institutionalization
In the West, for many, institutional i zat ion can lead to separation from significant others, lowered selfesteem, anxiety, and depression. For the residents of the St. Thomas Home, it may be reasonable to assume that the security of the convalescent environment was more frequently welcomed. For some it may have been the first time they had regular meals and respite from a wearisome existence.5
On the other hand, the loss of independence was a continuing problem for some, and the freedom of living on the streets was missed. The Mission's guarded gates prevented thefts from the outside, as well as kept the patients, many of whom were confused, from wandering out into the slums. This was for their protection as well as to keep them from begging, an activity strongly censored by the staff. In addition, since visiting times were limited and most residents were not integrated into the activities of the Mission, they were somewhat isolated in the home.
Needs for Affection and Intimacy
The openness of the wards, while compromising solitude, did seem to allow for even the most debilitated patients to enjoy companionship and social interaction. The residents and Sisters formed significant relationships, a supportive family-like atmosphere prevailed, and the able assisted those too frail to care for themselves.
Along these same lines, acutely ill children from the orphanage were housed temporarily on the wards. While this was not desirable from a communicable disease standpoint, many derived satisfaction from caring for the sick youngsters. Often a small child would be found sleeping in the arms of an elderly patient and women were observed brushing and braiding little girls' hair. In addition, several patients met some of their love and belonging needs by caring for stray kittens found about the facility.
Due to the lack of privacy, absence of marita! partners, and the conservative views of the church, sexual intimacy was not a subject freely addressed. Except for Sunday Mass, male and female patients generally stayed on their own sides of the wards and rarely interacted socially. This is likely a cultural issue. On the Mission grounds, boys and girls interacted exclusively with their own gender and on the streets of Vyasarpady, women walked and visited with other women and the men, likewise.
Roles and Recreation
Residents spent the bulk of their days resting or carrying out solitary pursuits in their beds. Group activities revolved around religious services and a few residents clustered for conversation on benches in the garden. Several times yearly a bus trip was held for picnics at nearby churches. Weekly television programs were viewed and radio was generally a daily event. Cultural, religious, and news programs were the most popular.
Several patients played a handmade board game, called "Dyam" which was similar to chess. Only eight residents were observed reading, during my three-month stay. This is not unusual in light of the cognitive and sensory deficits, and this population group's lack of formal education.
Some residents developed purposeful roles by sorting laundry, serving meals, and passing medications. Chalk was made to supply the Mission school. Occasionally women sewed and made baskets and men helped out with the vegetable garden and cow sheds. However, not all participated in these activities, and there were some complaints of boredom and feeling useless.
Spirituality and Death
Religion was an important part of the lives of most residents, and it appeared that they found the home a satisfying place for meeting their spiritual needs. Although the majority had converted to Christianity, most were originally Hindu or Muslim. Mass was held twice daily and there was prayer before each meal.
Christianity was introduced to India in the year 54 AD, and its development was naturally colored by the predominantly Hindu culture. Therefore Hinduism and Catholicism have intertwined to form a uniquely Indian expression of spirituality. For example, the Mission recognized Hindu festivals as well as Catholic holidays and celebrated both with zeal. Fireworks, sandalwood and candle offerings, jasmine garlands, and incense marked the events of both faiths.6
Specific Hindu religious services were not provided, however, nor were temple visits. Residents were encouraged to study prayer books and worship on their own. Muslim practices were supported in the same fashion, and alternate food choices were available for each, when beef or pork were served.
Death was viewed as a natural occurrence and extraordinary measures to prolong life, such as tube feeding and intravenous therapy, were not used for the old. Dying patients were kept comfortable and a fellow resident assigned to stay at the bedside to offer prayers and reassurance. Last rites were performed by a Mission priest. Following death the body was covered with flowers and placed in the chapel. The coffin was draped with decorations, and the funeral service was held on the wards for the residents.
In spite of almost overwhelming obstacles, the staff of the St. Thomas Home provided a supportive and respectful setting for the aged to live out their final years with dignity. What was absent in terms of resources and technology, was balanced by a sensitive and compassionate approach to patient care.
Communicable disease was an ongoing issue, related to high density living, inadequate sanitation facilities, a frequently contaminated water supply, and poor mosquito control. Although the facility offered some protection from these problems, the dilemma is societal, and effective solutions will require further economic development and progress in the community health system.
Although residents had vastly different sociocultural backgrounds and health histories, they had problems that could be compared to those experienced by some institutionalized elderly in the West. These included the presence of multiple chronic diseases, issues surrounding polypharmacy, and functional problems that prevented them from realizing their full potential. Boredom, feelings of uselessness, and the loss of independence were also present.
I hope these impressions will challenge others to become interested in working with the elderly in Third World settings. By looking at the strategies used by others we can develop new perspectives with which to view the care given in our own affluent society, as well as begin to recognize universal issues surrounding the needs of the aged. Documentation of collective experiences can provide the groundwork for the research that will be needed for future development planning.
- 1. Kinsella KG: Aging in the Third World. Center for International Research, U.S. Bureau of the Census. Staff Paper No. 35, 1988, vii-ix, 1-23.
2. Don Bosco Beatitudes. Don Bosco Beatitudes Social Welfare and Rehabilitation Training Center. Madras, S. India. Non-dated report.
- 3. Purissima S (Administrator, St. Thomas Home for the Aged· Abandoned, Madras, S. India) Personal communication.
- 4. EUopoulos C: A Guide to the Nursing of the Aging. Baltimore, Williams & Wilkins, 1987, pp 112-116.
- 5. Lekan-Rutledge D: Gerontological nursing in long-term care facilities, in Gerontological Nursing. Philadelphia. WB Saunders Co, 1988, pp 794-825.
- 6. Massey R (ed): All India. London, Apple Press Ltd, 1986, p 101.
- 7. Bennett EJ: Nursing in the developing world. California Nursing Review 1988; 10:14-18, 39-41.