The Old Folk's "Kindergarten" --Old People's Daycare in Taiwan

Around a ping-pong table, a small group of old ladies are playing table tennis. They may not be competition class, but they manage some respectable rallies.

At the mahjongg table, four senior citizens are playing China's national game with avid concentration. Though their old eyes peer through presbyopic glasses, their playing skills are second to none, and their cries of "peng!" and "hu!" echo around the room. Things are also lively at a large table on one side of the hall. Led by a volunteer carer, several old men and women are enjoying games of cards in twos and threes. As they busily play their rounds, they also chat about everything under the sun.

Amid the laughter, a few old gents sit quietly in corners, some drinking tea and reading newspapers, some nodding off to sleep, but all of them completely at ease.

Half past eleven is lunchtime, and the staff have ordered lunch boxes and rustled up a hot steaming soup. Eating in each other's company, the old folk enjoy their meal all the more. With their bellies full, they rest for a while, then each goes to his or her bed for a siesta.

After they get up again there is a folk dancing session, and then it's time for the part of the day the old folk look forward to the most: snack time. It's their favorite because for one thing there are tasty snacks to eat, and secondly after the snacks "class" will soon be over, and they can go home. Some wait for their families to fetch them, while some ask the staff to call them taxis, with those going the same way riding together; others take a bus home. Thus their day in daycare comes to an end.

Lunch is the high point of the day in a rural daycare center. After their meal, the old folk go home to tend the fields or look after their grandchildren.

The problems of old people in Taiwan

"An old man in a straw raincape and bamboo hat in a solitary boat, fishing icy waters alone in the snow.""Not a line from family or friends, old and sick with only a lonely boat for company." In Chinese poetry and paintings since ancient times, the old have always been portrayed as alone and lonely. Today, old people in Taiwan already account for more than 7% of the population--we have joined the ranks of the"aging societies."According to Department of Health statistics, the suicide rate among people over the age of 65 in the Taiwan Area is 24 per 100,000. This is far higher than the USA's 20.2 or Britain's 8.9.

So what has gone wrong? Why should a society which has always prided itself on honoring and respecting old people, today be a place in which old people find life unbearable?

According to research by Professor Lin Tsung-yi of the department of psychiatry at Kaohsiung Medical College, old people in contemporary Taiwan face five major problems: a decline in the respect accorded them, difficulty in lifestyle adjustment, in creasing chronic illnesses, difficulties in crossgenerational adjustment, and a loss of authority.

In the past, when it was rare for people to live out their "three score years and ten," an old person in the family was something to be treasured. But as the number of old people in the population has increased, the respect they enjoy has declined accordingly.

Furthermore, with the traffic chaos, rising crime and increasing distance between people which have come in the wake of urbanization, old people may be afraid or unable to venture out of their homes, and this severely restricts their living space.

An old lady at Taipei City Government's Fraternity House daycare center hits the nail on the head when she says: "In the old houses you could chat with people all around, but in these new places neighbors don't talk to each other any more."

In rapidly changing Taiwan, amid talk of progress and reform, young people are rushing to get ahead, while old people who stand in the way of progress are derided as "old bandits." Professor Lin Tsung-yi of Kaohsiung Medical College observes that because of the period Taiwan spent under Japanese rule, many old people now aged over 60 received a Japanese education, and so are very different in terms of both language and values from the younger generation, who have been influenced by Western culture. This generation gap makes old people in Taiwan today especially depressed and lonely.

Chronic illness is another important factor which makes old people weary of living. According to figures from the Executive Yuan's Directorate-General of Budget, Accounting and Statistics, 55% of people over 65 suffer some kind of illness. The most common complaints include high blood pressure, arthritis, heart disease, impaired vision, chronic lung disease, stroke and senile dementia.

Don't laugh! We might be old, but as the teacher says, "practice makes perfect.".

Children as a hedge against old age

An increase in the numbers of old people is a common phenomenon around the world. In many advanced Western countries, a comprehensive system for caring for the elderly is already in place. As well as pensions and free health care, many kinds of care and residential institutions are available to old people. In Britain, for instance, there are special centers catering for old people in various circumstances, such as homes for disabled old people, residential homes, daycare centers, lunch clubs and so on. Meanwhile old people's care institutions in the USA include residential homes, nursing homes and homes providing medical treatment. Many Chinese emigrants too don't have time to look after their elderly parents, and because of this in the well equipped old people's homes in Western countries one can also see many lonely old Chinese.

In Taiwan, caring for one's parents has always bee seen as a family responsibility, and the concept of raising sons to look after one in one's old age" is deeply implanted in the Chinese psyche. Be that as it may, because of changes in the structure of society and the family, the proportion of old people in Taiwan who live with their children is falling year by year.

At present, institutions in the ROC for the care of old people are mainly residential, and include ordinary old people's homes, as well as nursing homes to accommodate chronically ill, mentally ill or debilitated old people.

The quality of facilities and service provided by residential institutions varies widely. They are also far from cheap (fees range from NT$20,000 to NT$50,000 per month). Those old people who have nobody to provide for them and who are unable to support themselves are cared for at public expense, but other senior citizens' fees all have to be paid privately. Nonetheless, demand outstrips supply. For example, Sung-po Lu ("Pine Cottage"), a state-run, fee-charging old people's residential home, currently has a waiting list of one to two thousand prospective residents.

The shortage of residential homes does not mean that old people are eager to live out their twilight years in such establishments. Yen Mei-ling, director of the China Handicap and Health Association, who has spent six months with residents of an old people's home, says: "Old people's homes are equipped either like hospitals or like hotels--they don't feel like home." Professor Lin Tsung-yi of Kaohsiung Medical College says surveys show that 90% of old people in Taiwan would prefer to be looked after at home.

Many families today still adhere to traditional notions of filial piety, but do not have the means to provide a suitable environment for looking after old people at home, so that many people of the younger generation have to struggle with a painful dilemma. In this situation, a daycare system in which old people go to a day center where all kinds of activities and care are provided, and return home in the evening to enjoy family life, perhaps provides the best of both worlds, by catering to both the old people's and the younger generation's needs.

A Miss Chiang has been taking her father to the daycare center at Fraternity House for almost a year now. She says that over the past year her father has become much more cheerful. Since suffering a stroke, old Mr. Chiang has not been very mobile, and although his daughter used to prepare a packed lunch every day, she was always uneasy about leaving him at home alone. But now not only is the father more cheerful, the daughter is happier too!

After Mrs. Wang's mother-in-law developed senile dementia, she became completely unable to look after herself, and would often wander off and get lost. This created enormous difficulties for her whole family. Thus for Mrs. Wang and her family, the Fraternity House daycare center is a real godsend. "Even the neighbors say: "It's wonderful that somebody is sharing the burden of looking after her with you." Mrs. Wang says the center has not only lightened the load on the carers, it has also been a great help for her mother-in-law's condition. "At the center she has stimulation and relationships, and after a year there her condition has shown a clear improvement. For a time she was even able to make her own way home."

Live a day, learn a day. Look at the almost childlike pride with which this old lady shows off her work.

The best of both worlds

Compared with old people who are "forced" to stay in residential homes for years on end, the old people attending daycare centers must be counted the "lucky ones." Far from harboring thoughts of suicide, in fact they treasure life! Wang Tsu-mu, aged 80, is the residents' representative at Fraternity House. This hale and hearty old gentleman does volunteer work at the daycare center every day, and is referred to by the old people there as "The Manager." In his view, the biggest difference between them and the old people who live long-term in Fraternity House's residential home is that the people in the daycare center, who have sons and daughters, "would hate to die," while those in the residential home, who have no-one, "have no fear of death." "They talk about dying all day long, and when they meet at Chinese New Year they yell out to each other, 'You're not dead yet then!' But at the daycare center talking about death is taboo," Wang Tsu-mu says with a laugh.

In Europe, where daycare centers have been around for a long time, different centers are tailored to the needs of different old people, such as old people's health service centers, day treatment centers, day fitness centers and so on. The first old people's daycare center in the US was set up in 1947 with funding from the Menninger Hospital. Today, the US has hundreds of such centers nationwide. Furthermore, apart from daycare services, there are also so-called "respite services," whereby at weekends or family holidays, or whenever carers need rest and relaxation, there is a place which can step in by sending personnel to the family's home to care for the old person, or taking the old person in for shortterm care. Peng Yung-kuan, director of Fraternity House, says that daycare centers can make up for the shortage of places in residential institutions. Having old people cared for by the government during the day and by their children overnight is a workable way of splitting the burden of care.

According to traditional Chinese values, honoring and caring for the elderly is the family's unequivocal responsibility. But today's changing conditions make it difficult to live up to this ideal.

Low take-up

Old Mr. Yu, aged 71, has suffered a mild stroke. He says that after his stroke he began coming to the Evergreen Home's daycare center in eastern downtown Taipei; this year is his fifth year there. "At home I had nothing to do but watch TV. but here I can play ping-pong, sing or chat, and I enjoy myself much more." He says he pays the center's NT$2000 -a-month fee out of his own pension. Although he Lives with his son and daughter-in-law, he says he doesn't "meddle in their affairs at all," but simply lives his life as a contented old man,"just looking out for myself."

Seventy-year-old Mrs. Huang is cheerful, talkative and has many friends. She is "class leader" at the Evergreen Home's daycare center. Mrs. Huang has wide-ranging interests: she not only studies calligraphy, traditional Chinese painting, cartoon drawing, making pictures from torn colored paper, and qigong, she is even learning her ABC at a beginners' English class. She says with a laugh that of all the classes, the one she enjoys most is the "funtime singing" class, because "there's less pressure on you when you're singing!"

However, the happy life Mrs. Huang is leading today is the result of a period of persuasion. She says that during the day her sons and daughters go out to work, and she used to spend her days at home alone watching television and sleeping. Life was really dull. Six years ago Mrs. Huang learned of the daycare center from a newspaper, and very much wanted to come. But her eldest son was opposed to it. He said: "It's not as if you had no-one to look after you, why on earth would you want to go into an old folk's home?" Finally Mrs. Huang's daughter took time off to visit the center with her, and they both thought it wasn't bad at all, so they went home to persuade Mrs. Huang's son. Only then did Mrs. Huang's new life begin."My neighbors and friends all envy me, but some of them have to do the shop- ping or look after children, so they can't come here," she says.

Since 1985, local governments throughout the ROC have begun to provide old people's daycare services. Some of them contract this work to existing institutions such as Taipei City Government's Fraternity House or the Provincial Pingtung Relief Institution. Other centers are attached to old people's cultural and sporting activity centers, such as Taipei's Evergreen Home or Tainan's Municipal Geronto-Recreation Center.

But although old people's daycare services have been established for several years, not only have they not become widespread, public knowledge of them is also limited. Statistics from the Social Affairs Department of the Ministry of the Interior list only 13 of the 23 counties and cities in the Taiwan Area as providing old people's daycare services. According to last year's figures, there were over 1.5 million people aged over 65 in the Taiwan Area, but only 119,000 visits were made to daycare facilities. Not only are there gaps in the geographical coverage of daycare provision, most of the existing centers are still not full. For instance, the old people's daycare center at the Evergreen Home in eastern Taipei City has a planned capacity of 24 old people, but at present only 17 go there. It is the same story at the daycare center at Fraternity House: director Peng Yung-kuan notes that when the center opened in 1992 its projected capacity was 50 people, but to date the actual number of people attending has still not reached this target.

Because of their limited capacity, some centers have never dared to publicize themselves too strongly, and this is one reason why they are underused. But Wu Jui-yun, a counselor at Fraternity House's daycare center, has not only taken the center's descriptive leaflet to the offices of neighborhood chiefs all around, she has even gone in person to local temples and churches where old people gather, to publicize the center. But even with all these efforts the center is still not full.

Unlike the healthy senior citizens who attend daycare centers, most long-term residents in old people's homes are chronically ill and unable to look after themselves.

Providing the wrong type of care

In fact, the main reason for the lack of take-up of daycare lies in the disparity between provision and needs. Peng Yung-kuan says that the people who are really in pressing need of daycare are disabled and infirm old people who need personal care, and not the people that daycare services are currently geared towards: mobile, healthy senior citizens who are capable of taking care of themselves. However, the existing daycare centers are generally understaffed. Their two or three staff are already stretched to the limit looking after ten to twenty healthy old people, so they would be hard pressed indeed to look after sick old people.

Apart from this, transport and time are also factors hampering the promotion of daycare. Except in Kaohsiung County, where there are special buses to transport old people to and from daycare centers, the centers don't provide any transport, and this greatly reduces public willingness to use them. Furthermore, the limitations imposed by the centers' opening hours, which are tailored to the civil-service hours worked by the staff, make it difficult for most working families to fit daycare into their schedules.

Thus "taking geriatric care into the community" is the ideal solution for old people's daycare, and is also the direction in which the authorities will be actively working in the future. Kaohsiung County is the first area to implement community daycare. At present, the neighborhood development associations in such communities in Kaohsiung County as Shechung in Luchu Rural Township, Hsilin, and Chunghsiao in Kangshan Township are providing daycare services in neighborhood activity centers.

Health is the key to everything. The daycare center attached to the Cardinal Tien Center hospital is equipped with all kinds of exercise and rehabilitation facilities for old people's use.

Rural daycare

But as far as the development of daycare services in rural districts is concerned, it appears to be a case of "the government is willing, but the public isn't interested." For instance, in the Shechung neighborhood of Luchu Rural Township, there are some 200 people over the age of 60. Tsai Yen-liang, general secretary of the neighborhood development association, says that the activity center is well equipped with all kinds of leisure equipment such as pool tables, ping-pong tables, karaoke equipment, massage chairs, traditional tea sets and chess sets, but the level of use is not high. "Farming-type communities don't set that much store by leisure, and after eating lunch many old people go back to work in the fields," says Tsai Yen-liang with a laugh.

As one can imagine, the midday meal is the day's main event it geriatric daycare in a rural neighborhood. Daycare in Shechung is completely free of charge. The staff costs are paid by the Ministry of the Interior, and the cost of the food and its preparation is paid for by the neighborhood. Every lunchtime, 70 to 80 old people enjoy a free, nutritious meal at the activity center. One commented: "Cooking is so much trouble! Eating here together with everyone else I have a much better appetite."

On the other hand, Hsilin neighborhood charges for its meals. Each old person pays NT$20 and the neighborhood provides a subsidy of another NT$20 out of the interest from its construction fund, to provide old people in daycare with a self-service meal of four dishes and a soup. The village and borough liaison officer Yang Ming-jui says that the community is sharply divided on party lines, and as the neighborhood council is currently controlled by the DPP, old folk who support the KMT do not attend the center. In some cases old people think that going to the daycare center to avoid the bother of preparing a midday meal is a great idea, but their children's reaction is: "We're not short of money, why eat there just to get a meal on the cheap?" and they don't let the old people go there. Thus although the center has been running for over a year, the number attending has always stayed around 20 to 30.

Having finally laid down the burden of a lifetime of toil, how can old people pass their remaining years with dignity and independence?

Birds of passage

The old people who are most in need of daycare are those with restricted mobility or in poor health. But the shortage of medical and nursing staff in Taiwan, the high cost of providing such care and the fact that it is not covered by the National Health Insurance scheme mean that hospitals around the country have little inclination to set up daycare centers or residential nursing homes. At present only five hospitals are providing daytime nursing care on an experimental basis: the Cardinal Tien Center in Hsintien, the Monroe Hospital in Hualien, the Puli Christian Hospital, the Chiayi Christian Hospital and the Provincial Fengyuan Hospital.

For instance, the Cardinal Tien Center first applied in July last year for a Department of Health subsidy to set up an old people's daycare center, which is now attended by 20 old people. Every day it sends vehicles to bring the old people to the hospital, and apart from the regular visits by a doctor once a fortnight, there are also three nurses and three assistants in full-time attendance. "Most families want their old people to live in the nursing home full time, but from the hospital's standpoint we would rather they opt for daycare, so that the old people can go home in the evenings and enjoy family life," says nursing director Lu Hui-chen.

Daycare section leader Lin Hui-ling notes that daycare patients only attend for about two months on average. The reason they leave is not because they can't adapt, but because families take turns to look after their old folk, and when the time with one family member is up, the old person is sent to another place. "For the convenience of family members, the old people constantly have to move and readapt to new surroundings," says Lin Hui-ling, who is deeply sympathetic of the plight of the elderly today.

An old age of dignity and independence

"The concept of daycare for the aged is very good and very much in step with the needs of modern society, but I'm opposed to the idea of the family 'placing' the old person in care," says Lin Tsung-yi, who believes this takes away the old person's right of self-determination. He stresses the importance of letting old people make their own choices.

What is the best way to let old people live independent, dignified lives? Perhaps Norway, where welfare provision for old people has a history of over a century, can provide us with some lessons.

Ching Pao-lin, nursing director at the Cardinal Tien Center's nursing home, visited Norway this May to study their methods. She says that Norwegians retire at 55, and because of this people start very early planning their post-retirement lives.

In old people's centers in Norway, it is not the staff who supervise the old people, but rather the old people who supervise the staff. Whether in terms of facilities, care methods, or the content of activities, these are all requested of the staff by the old people themselves according to their own needs. In Norwegian old people's centers, it is the old people who are the real masters.

At the same time as we are beginning to study how to care for old people and treat them well, perhaps we should also start learning how to be old people ourselves in the future.

[Picture Caption]

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Old people's daycare can help reduce the burden on families while still fulfilling old people's need for a home life. Perhaps it is a workable approach to solving today's problem of how to care for the elderly.

p.110

Lunch is the high point of the day in a rural daycare center. After their meal, the old folk go home to tend the fields or look after their grandchildren.

p.111

Don't laugh! We might be old, but as the teacher says, "practice makes perfect."

p.111

Live a day, learn a day. Look at the almost childlike pride with which this old lady shows off her work.

p.112

According to traditional Chinese values, honoring and caring for the elderly is the family's unequivocal responsibility. But today's changing conditions make it difficult to live up to this ideal.

p.113

Unlike the healthy senior citizens who attend daycare centers, most long-term residents in old people's homes are chronically ill and unable to look after themselves.

p.113

Health is the key to everything. The daycare center attached to the Cardinal Tien Center hospital is equipped with all kinds of exercise and rehabilitation facilities for old people's use.

p.114

Having finally laid down the burden of a lifetime of toil, how can old people pass their remaining years with dignity and independence?