After a fatal fire at an unregistered nursing home and a string of reports about seniors living alone being found at home dead, people can't help but wonder: Is Taiwan really a paradise lost for the elderly? Just exactly what kind of lives do old folk in Taiwan lead? And what are the govern-ment's policies toward them?
At the Evergreen Seniors' Activity Center in Neihu, 73-year-old Liu Yao-wen is shooting pool with eight old men and women.
Liu, a retired soldier, has 40 or 50 friends here with whom he frequently plays ping-pong and pool. But he describes himself as the "most shameless of the bunch" because he comes every day and stays a long time. After leaving early every morning to practice waidan breathing exercises, he goes back home for a nap. Then he rides his bike to the center, where he shoots pool and chats. At noon he goes home to eat and take a short siesta, but then comes back in the afternoon to shoot some more pool.
Liu, who has both friends and the support of his sons and daughters, is happy with his lot in life. He says that he personally lacks nothing, and that his complaints lie only with the general social environment. "I've lived here for 50 or 60 years, but people here still say that I'm a mainlander, whereas over there they say I'm Taiwanese. Poor me!"
Wu Wan-fang is a 73-year-old spinster. Her brothers and sisters have all passed away and she rarely sees the niece who is her sole relative in Taiwan.
Wu, who has a university degree in foreign languages, made her living teaching English. Today she gets by with a monthly check of NT$11,000 from the government under a welfare program for low-income households.
Wu lives by herself in a walk-up apartment on the sixth floor of a decrepit government-subsidized housing project. The apartment of 300-some square feet is filthy, full of broken furniture, newspapers and garbage.
Every evening at six or seven o'clock, Wu, who has had a successful lumpectomy but has high blood pressure and impaired mobility, takes 30 or 40 minutes just to go down the stairs. She eats dinner; buys a newspaper, bread and milk; and then takes the opportunity to watch the television news at the superintendent's office downstairs. If you ask her why she only leaves her house for one meal a day, she says with a thick Shanghai accent, "Going down six flights of stairs is a lot of trouble. I'm only able to do it once a day."
The Elders' Foundation at once arranged for Wu to enter a private nursing home. Unwilling to share a room with others and uncertain she would like the food, she refused.
Lonely twilight
Among those passing their last years in Taiwan, some live in institutions, others enjoy the care of their own children, and still others are living by themselves. Some of these seniors are full of vim and vigor; others, poor and sick, lead bleak lives.
In the past, how well one was provided for as a senior depended, for better or worse, on how filial one's children were. But as family structures have changed, children have become unable to bear the responsibility of caring for the elderly all by themselves. As a result, the soundness of welfare planning for the elderly has become more and more important.
Apart from free bus rides and free hospital care under the National Health Insurance system, what welfare benefits do the elderly now enjoy?
Those who are in good health can make use of the seniors' activity centers found in many neighborhoods and join the various activities and classes held there.
Old people from middle- and low-income families whose total monthly earnings fall below 2.5 times the minimum for monthly living expenses (which in Taipei is set at NT$11,443) are entitled to monthly government welfare checks.
Seniors who are all alone can apply for the government to put them into a government-supported seniors' home.
From the look of it, government-supported programs for the elderly in Taiwan are quite limited. There is, moreover, a polarizing effect: welfare benefits are limited to low- and middle-income seniors, whereas government-supported seniors' facilities can only be accessed by able-bodied elderly. It's no wonder that people complain that the vast majority of elderly-those who are neither among the fittest nor the poorest- are left without any benefits at all.
An imbalance of supply and demand
What benefits do the elderly most need?
A 1996 "Survey of Seniors' Living Situations" carried out by the Ministry of the Interior reported that seniors felt the government should make it a top priority to provide the elderly with emergency medical care, government-subsidized pensions, and in-home medical care.
Since the National Health Insurance scheme was established in 1995, seniors have been assured of basic medical care. Generally speaking, emergency medical care isn't much of a problem. What is a problem, however, is long-term care. Wu Shwu-chong, an associate professor in the Institute of Public Health at National Taiwan University, believes that the government most needs to take the lead in the area of long-term care.
Statistics show that nearly 60% of the 1.6 million elderly in Taiwan suffer from chronic illnesses, and among these 90,000 require long-term care. About 19,000 need to enter nursing homes.
But the supply cannot meet the demand. According to Bureau of Health statistics, Taiwan's 29 nursing homes and nine daytime-care facilities provide only 1100 beds, a far cry from the number needed.
Chen Show-mei, who works in the Bureau of Health, points out that the bureau once encouraged the government to increase the number of beds allotted to chronically ill patients. Because the elderly population was rapidly growing and health-care costs were rocketing, they advised a new focus on encouraging the establishment of nursing homes. But National Health Insurance pays for hospitalization of chronically ill patients but does not pay for nursing homes, and so hospitals are being flooded with elderly suffering from chronic illnesses.
Hard to be filial
Because government standards for equipment and staff in nursing homes are high, such homes are expensive to operate and most are affiliated to hospitals.
Apart from these registered nursing homes, there are also many privately run, unregistered nursing homes that provide similar, though inferior, services.
With a limited number of registered nursing homes, and with these very expensive, many people set their sights a little lower and choose an unregistered home.
Last year, a Mr. Hsueh's father went into a coma after being involved in an auto accident. Because his home lacked a proper hospital-type bed and respirator, and so that it would be convenient for his mother to travel back and forth, Hsueh put his father into a private nursing home nearby. "They said that Dad wasn't easy to take care of," Hsueh recalls, "and they wanted more money." Hsueh was very dissatisfied with the home, which he regarded as only being interested in maximizing its profits.
According to a study carried out by the Bureau of Social Affairs at the Ministry of Interior at the end of 1997, there are 597 unregistered nursing homes in Taiwan, which could hold 18,000 residents but now hold only 9000.
Where does the money come from?
Can the problem be solved simply by having National Health Insurance pay for nursing homes? According to National Health Insurance Bureau statistics, long-term medical care for the elderly would start at NT$10 billion a year and rise quickly. So as not to disrupt the National Health Insurance system, it is necessary to find another source of funds.
At the "1997 Asia-Pacific Elderly Care Symposium" put on by the Health, Welfare and Environmental Foundation, Lu Jui-fen, an associate professor of health services management at Chang Gung University, explained that the method each nation uses to fund its long-term care of elderly is closely related to that nation's social welfare system. The welfare states of northern European nations and Australia rely on tax revenues; Germany and Japan have built up a funding base from social security insurance payments; and Singapore employs a system wherein employers and employees jointly contribute to an individual retirement account.
Chen Show-mei points out that in Taiwan long-term care costs can not be borne by the National Health Insurance system, and creating a pension system for the elderly or an additional insurance system would be more feasible.
Currently the Department of Health plans to encourage some poorly managed provincial hospitals and various other hospitals to turn into nursing homes, providing more than 10,000 new beds for those in need of long-term care in the next three years. This would help to ease the problem.
Relying on oneself
Apart from health care, economic measures also need to be taken to protect the elderly.
Currently, the bulk-some 50%-of the elderly's living expenses are paid by their children. But surveys reveal that each year the elderly rely more and more on pensions and social welfare.
Although elections bring bold calls for government pensions and welfare benefits for the elderly, once the ballots have been counted these plans fizzle in the face of budgetary constraints.
Elderly who have retired from their jobs cannot bank on "now you see them, now you don't" company pensions for the rest of their lives. In which case, must they save for a rainy day?
"Savings can not replace government pensions," argues Lin Wan-i, chairman of the sociology department at NTU. "Savings, lump-sum retirement payments and corporate pensions can fall in value, or be lent to others or invested poorly so that they may even disappear entirely. Government-provided pensions, however, can't disappear, and one can't be cheated out of them. They can truly ensure that the elderly's basic economic needs are met.
Li Hsiung, executive director of the Elders' Association, points out that there are many cases of "society's economic abuse" of the elderly, where old folk lose all their money after being cheated or making poor investments playing the stock or future markets. "Afterwards many elderly can't bear the thought of going on, and they hang themselves." Some old folk are cheated out of their savings by their own children. For instance, a Mr. Lin from Neihu tells how his daughter and son-in-law got him to sell his house last year and take all his savings to them in Canada on the pretext that they were arranging for him to emigrate there. It was only when his passport expired and he was forced to return to Taiwan that he realized that his daughter had made no such arrangements. Now he gets by on government assistance and delivering newspapers.
Some say that what seniors need most isn't money but rather care. Yet Lin Wan-i points out that while it may be that money is not so important before long-term care facilities are established, once services at these facilities are available, money will be required to pay for them. Given that, how can one say that it isn't important?
The Council for Economic Planning and Development is now designing a social security system which is to be established in the year 2000. But according to current plans, only those old folk who pay into the system for 40 years can enjoy full annual benefits. People who reach old age in this period of transition must have another source of income to ensure their economic livelihood in old age.
Service comes home
In-home care is the third major need of seniors. Currently, it is provided through two channels: The Department of Health sends nurses to the homes of the elderly, whereas government social-service agencies provide in-home care of a non-medical nature.
Chen Show-mei points out that currently 148 nursing homes have contracts with the National Health Insurance Bureau to dispatch health care personnel to the homes of the elderly and to dress wounds, deliver medicine, change intravenous tubes, and so forth.
There are 4800 seniors who receive such care in their homes, and the National Health Insurance Bureau spends an average of NT$9000 a year on each of them to provide these services.
Yet many of the elderly patients are dissatisfied with the care, mainly because the nurses visit so infrequently that they are of little practical use. "Can you change the dressing and medication on a wound just twice a month?" Old folks still have to make visits to the hospital themselves. Chen says that the National Health Insurance Bureau is currently discussing and researching plans to raise the number of visits.
In some of the 18 counties and municipalities of Taiwan, charitable organizations staffed with volunteers provide these services, and in others local government agencies do.
Since 1983, Taipei City has provided residential care for low- and middle-income people. This includes helping them with housework, accompanying them to the hospital, delivering their medicine and providing in-home nursing.
Because there hasn't been enough promotion, few people know how to make use of this help. In 1990 the targets of these services were expanded and private service organizations such as the Red Cross and Red Heart were contracted to provide care.
Red Heart provides in-home nursing in about 100 Taipei homes. About 80% are low- and middle-income families, for which the government subsidizes these services. The remaining 20% pay for the services themselves. They are charged NT$225 per hour, which means that if they are using nurses eight hours a day, the monthly charge comes to NT$45,000, which is about 25% cheaper than what they would pay on the open market. Still, because these organizations can't find enough workers, they can provide very little compared with the overall needs of society.
A daughter sent by God
Chen Mei-chun, who is in charge of in-home nursing for Red Heart, says that for most families the greatest pressure in caring for the elderly comes when there is need for long-term care.
For five years, a Miss Kao has been using at-home care for her father, who suffers from heart disease, high blood pressure and asthma and needs someone nearby at all times. With a child and in-laws to take care of, Kao has simply more people to look after than she can handle herself.
"When a daughter marries and leaves her parents' home for her husband's, she can no longer easily justify taking care of her parents," she says with frustration. Having in-home nursing to act as her proxy in the role of daughter is a big help. "Rather than calling it sloughing off your responsibilities, call it sharing your burden," says Kao, articulating the frustrations of a modern Chinese daughter.
A Mr. Yu, who works at a magazine, only works half days so that he can take care of his elderly father. Over 40, he is still single. When you ask Kao and Yu about the future, they both feel a bit at a loss, but they are unwilling to send their parents to nursing homes.
Mrs. Wang has no children. Since taking a nasty fall, it has been hard for her to move about. Apart from some kind-hearted neighbors who provide for her food and basic living needs, a trained professional from Red Heart comes to her house twice a week to clean up and accompany her to the hospital. She often says that the woman who provides these services is a daughter given her by God.
Staff in charge of in-home care at the Taipei City Bureau of Social Affairs explain that in addition to the assistance provided to low- and middle-income families, next year they plan to introduce "breather services" of 16 hours a month, so that anyone taking care of an elderly family member, regardless of family income, can have some time off. Chu Su-chen roughly estimates that 3500 households could be eligible for this program.
Toward community-based care
Coming to the home to provide services provides tremendous support for families with elderly in need of care, and it does in fact jive with what most old folk want and most families need.
Research undertaken by Wu Shwu-chong of NTU reveals that 60% of people aged 20 to 64 believe that it is best for elderly with disabilities to stay at home; another 30% think that community-based care is best; and only 10% agree with sending them to institutions.
In a survey on the health and long-term care of the elderly in Taipei, about 80 percent of those who provide care to an elderly member of their family say that they would never consider putting these seniors in institutions, even if their health declines further. In that event, they hope that either their spouse or child will quit their job to stay with the senior at home, or else they hope to pay for in-home nursing.
Take the case of Ms. Wang, who is a writer. Her father, who is bed-ridden and very ill, cannot bear not to see his only daughter every day, and she, too, isn't willing to send her father to a nursing home. Wang, who is very busy, pays NT$2000 a day so that her father can have a professional nurse, and also employs a Filipina maid to cook and clean house. The expenses of caring for her father add up to NT$80,000 a month, which would be a major burden for any family. Although in July the government will start providing a NT$15,000 monthly subsidy for seniors who need care, this will be restricted to low- and middle-income families.
Most of those who put their elderly family members in homes feel great remorse about it, and fear other people's reproaches. Wu Shwu-chung recalls that she once wanted to conduct research on families with elderly relatives in institutions, but most of them refused to cooperate. She explains, "They would say, 'Putting a family member in an institution is a painful process. Please don't come and stir up the pain all over again!'"
Old folk themselves are even less willing to enter nursing homes. Surveys show that only 11% of seniors with chronic illnesses who need in-home care are willing to enter nursing homes.
Lin Wan-i points out that this generation of old folk born before the war have very close connections with their families and locale, and very few of them have had much experience with leaving their hometown to work or study or living away from their families. Few can accept the idea of leaving their families for institutional care.
Between families and institutions
Apart from in-home and institutional care, is there another choice for treating the elderly? Perhaps community care is the solution.
Lin Chao-wen, who works in the Bureau of Social Affairs at the Ministry of the Interior, says that in the future the government will begin to push policies that encourage more community-based care.
In fact, in recent years Europe and America have been moving away from institutional-based care and toward community-based care.
Whereas Europe and America formerly had policies to encourage the elderly to enter nursing homes, the proportion who actually entered homes has never in fact been very high. With costs rising out of control, from the 1980s these nations began to shift their policies to favor the establishment of community-based care networks.
Apart from strengthening in-home care, service networks are being tailored to the needs of the individual community. Lin Chao-wen points out that the Bureau of Social Affairs will stop assisting the establishment of large-scale nursing homes, and will turn its focus to smaller institutions and community-care organizations, so that the elderly can remain in their own homes and communities whenever possible.
The United Nations has declared 1999 the "International Year of the Elderly." How to go about providing the elderly with twilight years of happiness and dignity is something that tests the wisdom of each nation.
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Childhood sweethearts accompany each other through old age. One-third of all elderly who need long-term medical care are cared for by their spouse. (photo by Diago Chiu)
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People live alone for many different reasons, but the dangers and difficulties these solitary seniors face are much alike. This is a pressing problem for society. (photo by Diago Chiu)
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Old folk hit the streets in a demonstration calling for the establishment of a basic social safety net.
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In-home care is well suited for elderly who don't like to leave home.
p.12
After spending a lifetime of working hard, who expects to find themselves with nothing, living out their final years on the street? Is the idea of "golden years of plenty" just a dream?
p.15
Life is short, so keep singing! Enjoy the moment and don't bother what the future might bring.
Old folk hit the streets in a demonstration calling for the establishment of a basic social safety net.
In-home care is well suited for elderly who don't like to leave home.
After spending a lifetime of working hard, who expects to find themselves with nothing, living out their final years on the street? Is the idea of "golden years of plenty" just a dream?
Life is short, so keep singing! Enjoy the moment and don't bother what the future might bring.
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