Report on Old Age A LONG, CHILLY AUTUMN

By HERB GREER 0 it's a long, long time from May to December but the days grow short when you reach September, and the autumn weather turns the leaves to flame. Then one hasn't got time for the waiting game. ...

TilosE are the words of a love song written by Maxwell Anderson and Kurt Weill some Years ago for an old man to sing. The song echoes a certain familiar sentiment about old age that it means the autumn years, the time of peaceful relaxation, the gentle time of rest, well earned after a life of work, the quiet period after retirement when one may settle down in the rich maturity of years and contemplate one's past life and memories, enjoy- ing the respect and care of the younger genera- tion. Shakespeare wrote about it, too, in a famous sonnet which ends like this: In me thou seest the glowing of such fire that on the ashes of his youth doth lie, as the death-bed whereon it must expire, Consumed with that which it was nourished by. This thou perceivst, which makes thy love more

strong, to love that well which thou must leave ere long. Ah, yes.

Suppose we have a look at this object of so Much presumed love and respect and see what really happens to it—biologically, for example. The process is something like bending a piece of tough wire back and forth until its resistance Weakens and it snaps. In the wire this is called metal fatigue. The parallel (and inevitable)

Process in the human body is called age—old age.

The skin becomes thin, yellowish and wrinkled, especially in the hands and neck. Senile lentigines (liver spots) appear on the hands and face. Warts develop which may become malignant. Arteries become sclerotic and veins are prominent and often varicose, decorating the legs with blotted Patches of blue. A general pruritis can develop too. That means you begin to itch all over. Your hair, if you still have it, goes grey and then white. So do your eyebrows. Your slacken- ing muscles won't respond properly and your gait settles into a senile shuffle. The simple act of getting out of a chair is a clumsy, ponderous struggle. Your hands tend to fumble and shake. Inside the body, your weakening heart can't PurrIP as well as it did and so your limbs, cheated a good supply of blood, feel cold. Shallower breathing makes you prey to bronchitis, pleurisy, °r Pneumonia which may, if you're lucky, kill You before the final ravages of senility. Your body can't keep its calcium. While your teeth are falling out, your bones are slowly softening, bending under the weight of your 'ciclY. The upper spine curves forward into that elderly hunch. The joints are stiffening, and that autumn weather which turns the leaves in the gong to flame, burns your knuckles and your Wrists with a dull arthritic fire.

If you survive these and other unpleasant physical disabilities you will find your nervous system beginning to rot. Your eyes have an opaque cast around the iris, the arcus senilis, which gives your gaze a flat lacklustre expression. You may go blind, evoking pity in those around you. On the other hand, you may go deaf, which is more likely to cause irritation and grudging tolerance. Your sense of smell fades and you may find yourself piling condiments on your food to make up for your failing taste buds. Parkinson's disease may hit you and reduce you to a jittery drooling wreck.

Your personality undergoes certain changes, notably a lessening of the inhibitions which have so far kept your unendearing qualities in check. You become self-pitying, selfish, jealous, posses- sive, aggressive, or obsessed with some impulse, like a packrat fear of throwing anything away. Your memory for recent events dissolves, but episodes from your childhood pop into your mind with amazing clarity. Insomnia can drive you into wandering about the house at night. Your aged peevishness may become so extreme that you sink into a childish mental twilight, wetting or fouling yourself to make sure you get attention. And those giving you attention may have to restrain you from devouring your own excrement.

It's also possible ' that you may remain mentally sound enough to look into a mirror and feel, as Yeats did, that you are trapped in a dying animal. But as you 'probably don't have Yeats's talent to occupy your time, the grinding knowledge of your uselessness bores into your soul, you realise that you are good for nothing but to die, and you sink into a state of hopeless apathy. When at last death does arrive in any one of a hundred ways, you have no more will to resist it.

Now this description does lump together a lot of very unpleasant symptoms which in fact take years to accumulate. In the actual course of events, they do not prevent a majority ,of people from leading a relatively healthy exis- tence well into the years after retirement. One still reads of an old woman in Turkey who was born in the eighteenth century and is chipper enough in 1963 (women seem to withstand the ageing process better than men), or of an old man who at eighty-one sets out to realise his life's ambition to walk from John o' Groats to Land's End. But these are exceptions. Normally the diminishing powers of the ageing person take him more and more out of the active stream of society.

In Britain retirement comes as a blow to many, particularly in the working class. It destroys the man's status as a bread- winner and, often, the self-respect that went with it. Women, whose existence is usually more centred in the family, can remain the focal point of the group into old age and so retain their sense of usefulness. In the higher social strata

the means, financial and otherwise, for coping with retirement can ease the severity of the shock. But once past the age of retirement, people are thrown into a new existence which almost always has to centre around their family. And if the children, once grown up, move away, the ageing parents are left more and more on their own. Many such people cannot manage to sustain a decent existence by themselves and, wil- ling or not, they become a public responsibility.

The vast majority of sold' people—over sixty- five—who need care still get it from, their families. Yet fifteen to twenty per cent of the seven and a half million elderly Britons dO be- come partly or wholly clients of one welfare service or another. Public authorities or any one of a multitude of voluntary organisations may help to feed them, clothe them, care for them medically, amuse them, employ them, or give them a place in an institution of some kind—or, if they are middle class and lucky, in a voluntary or statutory sheltered housing project. Along with other objects of welfare concern, these old people become members of an ancient and honourable group. It has no official name, but we may call it the Human Garbage Club.

This club has a history reaching back into the roots of European civilisation. Under the Byzantine Empire it ' was scattered among various church-run establishments: Nosocomia for the sick, Ptochia for the helpless poor, Gerontochia for the aged, and so on. In mediaeval England monastically governed houses of pity and infirmary almshouses cared for the ill and socially outcast. After the monas- teries were wrecked, the Poor Relief Act of 1601 established Poor Houses which served as general social dumps. These chilly pits housed the blind, the destitute, the outcast, the mad, and the aged and infirm. They were the first official meeting .houses in England for the Human Garbage Club, where all the offal could assemble and mingle indifferently.

The aged poor, along with their other club members, remained essentially human garbage until the nineteenth century, when a use was found for them. Medical science had an urgent need for human guinea pigs. A system of volun- tary hospitals began to emerge, partly because of this need and partly because of human charity. But the Poor Laws still dumped the aged in together with the rest of the outcasts. The official attitude was that if you were old and poor, it was your just deserts for a misspent life. Accordingly you should be treated severely like all the other undeserving tramps and waifs and strays. A number of seventeenth-century workhouses were used to stable these dissolute people, and bigger and better workhouses were built so that the labour of the inmates might increase the national wealth. The club still had its meeting places.

However, the idea did dawn here and there that some of the poor, even the aged poor, might provision was made for the aged, though it was pitifully small. What classification there was tended more to be based on deportment and behaviour. Generally such institutions as isola- tion hospitals, labour exchanges, and of course the workhouses functioned mainly on the assumption that the aged were no different from any other object of welfare.

In 1909 the minority report of the Royal Corn- Mission on Poor Laws mentioned establishments where only the aged were housed .. . a thousand or two out of 140,000 in all the poor law insti- tutions. It was a vague and naturally uncon- scious hint that the aged poor might in some way be different from their fellow garbage. And in 1900 the first non-contributory old-age pensions were created: one to five shillings a week. Another hint. Nobody took it.

Twenty years after the above minority report, the whole problem was taken out of the hands of Boards of Guardians, who were resisting

administrative reform, and given to counties and county borough councils. The best of the 'public

assistance institutions,' as they were beginning to be called, were converted partly or wholly into hospitals. Somehow the idea had seeped into the welfare mind that outcasts could be classified as healthy and sick.

Little was done to improve or enlarge the institutions during the 1930s, though a few smaller

ones for the old appeared. They offered a few more comforts and a bit less of the nineteenth- century sternness. At the beginning of the

Second World War these islands of comparative enlightenment amounted to less than a twentieth of all the accommodation under Public Assist- ance Committees.

The drain on public services during the war Produced a certain worsening of conditions. But after the war the picture began to change. In

1944 the Nuffield Foundation appointed a survey committee which aired the appalling

conditions in public assistance institutions. It also noted that a majority of the inhabitants Were aged. In 1947 the committee recommended

that old people who could not live an indepen-

dent life should be housed in small homes rather than in large institutions. A number of such

Places did exist by then, run mostly by private charitable and religious bodies. That same year Aneurin Bevan, introducing the National

Assistance Bill; announced that the workhouses Would go. There was to be 'a great departure in the treatment of old people.' But not, it would

seem, in the manner of thinking about them.* Meanwhile the press was giving attention to the social problems of the aged. The Times noted the rise in the numbers of Britons over sixty-five: 1,750,000 in 1900: 3,750,000 in 1937. For 1955 a total of over five million was predicted. Even the attitude of the popular press was changing. Before the war one could find a doctor stating fatuously in the Daily Express: 'Old People should never ask themselves what use they are In the world. Nor, indeed, should anyone.' That sort of tripe, along with the usual bromides like a Man is as old as he feels,' and 'only those who e ase to fight in life's arena grow old,' were d *Most of the facts in this historical outline are drawn from Chapter 2 of The Last Refuge by Peter uwnsend. The interpretation, however, is my own.

also agreed that some effort should be made to preserve his sense of usefulness. This was hardly ever achieved, but at least the idea was there. Along with the workhouses, there was another survival from an earlier time: the idea that the aged in need of care and attention are no different from any other welfare problem. The peculiar justification for this belief was that one must at all costs avoid cutting the elderly oil from the community.

In 1960 Dr. Robert Kemp observed in the Daily Telegraph that the British had always been cruel to those who are feeble, friendless and old But was this still true, considering all that was being done? Aside from all the rest, the University of Liverpool had pioneered the year before a 'preparation for retirement' scheme. It was to begin in the person's fifties and lessen the impact of the change from work to no work. This was local, but it was a good idea. At the same time, the elderly were often encouraged to enjoy their retirement by moving away to the seaside. That is, they were asked to leave their family and friends, go away to where no one knew them, set up house alone, and when they were infirm (the propaganda failed to add), they would be hope- lessly stuck and alone, good candidates for admission to an institution. In June, 1960, the Bishop of Exeter made his contribution to thought about the aged. He questioned whether it was morally right to keep the old and infirm alive by extraordinary means, and added that it was important to distinguish between euthanasia and the administration of pain-relieving drugs in lethal quantities.

Voluntary agencies and the various ministries and local authorities were still plugging along, trying to meet the rising demand of the aged on welfare services. The object, ideally, was to keep them in their homes as long as possible, since this was recognised as giving the maximum chance of a decently happy life, even when the old were infirm. And for people who could afford them, there were a fair number of private homes. So that when the family could no longer contain the old person, or he was alone and had some means, he could go to such a place and live among company and have some of his needs attended to. These places were, however, for elderly people who were reasonably healthy ambulant members of the middle and upper classes.

Some programmes existed of partial help for old people still at home: visiting services, delivery of meals," old people's clubs and cheap holidays. And the idea was growing of working centres where the elderly could usefully occupy their time and earn wages in jobs suited to their limited abilities. This could alleviate the corro- sive fear of uselessness which so often haunts the declining years.

After another year of surging progress, another remark appeared in the press: The British, so soft-hearted about dogs and tigers, are emo- tionally tough in their attitude to children (those not large enough to hit back) and particularly to the old. A letter to the Guardian suggested that the Ministry of Health do something more about the old than issue exhortations which nobody seems to pay much attention to. One Trude Schulz burst into print with the news that twenty-five shillings could nourish a human blandly served up to the public. And in the back- ground a major social problem was looming up.

After the war the sludge still flowed. One could find articles on 'How Would You Like to Live to Be One Hundred?' But it was leavened by a new note of protest, often sentimental and strident and seldom suggesting any useful measures. Social legislation did take note of the aged.: Sections 21, 31 and 47 of the National Assistance Act referred to them. Geriatric units were set up under the National Health Service. The Ministry of Pensions and the Ministry of Housing also had certain responsibilities for the aged who needed accommodation and money. Voluntary organisations such as the WVS, the British Legion, the Roman Catholic Church, the Distressed Gentlefolks' Aid Association, and a host of others, also concerned themselves with helping the aged who needed help. And even as far back as 1940 the National Old People's Welfare Council had been formed as a national, focal point for information and advice on the elderly. Independent of politics or denomina- tions, it aimed for a co-ordinated nation-wide service for the care of the old in need of help, including both statutory and voluntary assist- ance. With all that effort on behalf of the elderly, one might be forgiven for imagining that they really had it made by now. When in 1950 a group of scientists in Belgium considered how to make people live to 150, one could think that it might not be so bad, really.

And yet—one still reads of old people found starving, or dead from starvation. As late as 1953 the Guardian published a horrifying account of an old woman found by a visitor, suffering from a broken wrist, delayed shock, and her body from hips to knees a mass of raw meat, with gangrenous patches sloughing off. In 1954 there was another story about old men living in Salvation Army Hostels in Bournemouth. When they became ill they were left on city doorsteps for the police to find, and taken to hospitals as casualties. It was the only way they could get hospital beds.

At the same time social thought about the aged progressed. It was generally agreed that work- houses were bad. They were still very much part of the welfare scene, of course, and many felt that they might be around for quite a while—say until the end of the century. But they were bad, most definitely. The ideal was now smaller homes, 'sheltered housing' based on the unit of the single room, which would preserve more of the old person's integrity and dignity. And it was 'I know, let's sack Rome.'

being sufficiently to allow him to survive. This was in the context of a general feeling that pensions were insufficient. The feeling was borne out by the Cole Report in January of 1962, which revealed that nearly two and a half million old people in Britain were living near or on the poverty line set by National Assistance standards. It was not established how many were not drawing national assistance and still living like that. Some were, though. The Medical Officer of Health in Twickenham publicly expressed his shock at finding old people who were starving.

And all the time, slowly slowly, the proportion of old people in Britain was increasing. The social services were growing too, trying to keep up with the staggering challenge of old people's welfare. Research was undertaken, and much had already been completed. One could see in the newspapers and on TV and hear on the radio that something had to be done. Jonathan Miller could report in the Observer that despite the research, 'the main burden of geriatric medicine falls on the shoulders of those who have become, over the years, accustomed to steering the aged patient around the awkward gaps in medical knowledge.' He pointed out also that every spell of smoggy weather exposes the fact that present geriatric services barely contain the problem of aged medical care.

Toward the end of 1962 Peter Townsend published his survey on residential institutions, The Last Refuge. It disclosed that with all the research, good will, and everything else, some- thing like fifty per cent of the old living under public welfare care were languishing in wretched nineteenth-century workhouses, some of them under conditions which would make a brass monkey sick to its stomach: half-brutal and ignorant staffs, boredom, filth, apathy, the most revolting kind of degradation—for instance, the bathing ceremony in which a new resident is forcibly washed and -scrubbed in order to break him to his new life in the institution. Though institutions of a better sort did exist, it appears that those who were not of genteel or middle- class origin stood little chance of getting into them. Licensing and inspection procedures for voluntary and private homes were erratic where they were enforced at all, and few of the people who concerned themselves with caring for the elderly in private, public or voluntary institutions had any particular training for the work.

Townsend offered suggestions to simplify the present incredible complication of responsibility for the aged: Creation of a comprehensive local family help service, concentrating responsibility for individual old and handicapped persons' welfare in one department.

Administration of all communal or institu- tional accommodation for the elderly by -hospital management committees under general direction of regional hospital boards.

All communal homes not publicly owned to be regularly and rigorously inspected and registered.

No homes with permanently incapacitated residents to be run for private gain. (This would probably prevent cases arising like an appalling one cited by Townsend in which an obviously ill-managed firetrap, run by a convicted embezzler, was still operating in spite of numerous complaints.)

All workhouse accommodation should be abolished within a fixed period and replaced by

geriatric and chronic sick hospital units, short stay homes, and sheltered housing.

In consultation with the National Old People's Welfare Council, the creation of an independent Central Welfare Board to co- ordinate and advise voluntary bodies on the provision of welfare services.

There is some resistance to the idea of putting communal homes under hospital committees. It is felt they would assume the air of hospitals and be invaded by medical personnel. Considering the wretched state of medical care in many of the present institutions, this might not be a bad idea. And since so few of the present staff personnel have any particular training for their jobs, the appearance of medically trained staff would Seem desirable—if they actually did appear, which is a pretty vague assumption. The objection is not really very convincing. One might even say that it's mealymouthed. Another comment is that the elderly might feel they were going into hospital, never to come out, and this would be psycholo- gically bad. The answer is that the present communal institutions inspire that feeling any- way—at least the ex-workhouses do. Indeed there's no evidence that any communal institu- tion would be less attractive because of a more efficient administration.

The other suggestions have inspired 'interest' and 'study' but no action as yet.

Social service for the old in Great Britain form a tangle of strands that is almost beyond belief. There is no pattern, unless it be a wildly shape- lessly crazy-quilt with gaps, ragged edges, and a hundred different sorts of material. Certainly the quilt doesn't keep as many people warm as it ought to. The closest thing to a national agency for the elderly is the National Old People's Welfare Council, which does keep track of research and makes an effort to list what has been done. It also runs training programmes and issues much information. But there is no machinery for evaluating results of research on a national level and funnelling it into national policy, though civil servants do sit on the Council. The Council does make an occasional approach to a Minister, as they have done recently over pensions. But as far as the Govern- ment is concerned there is no national welfare problem with the aged. There is only the Bristol problem, the Birmingham problem, the New- castle problem, the London problem, and so on. And this is in the face of the cold fact that in the near future the elderly will make more demands upon the social services than any other group in the population. At the moment the only official recognition of this phenomenon amounts to a vague hope that local authorities, in all their varied splendour, are going to do the right thing by their respective welfare clients. It is like the suggestion in the Health and Welfare Plan just published, that authorities which pro- vide too little home nursing care 'will need to consider whether their assessment requires revision.' One could tactfully suggest some reassessment on a higher level.

An astonishing number of otherwise sensible people still insist on clinging to the quaint idea that the elderly are no different from anybody else. Besides the rather spectacular biological differences mentioned earlier, one might point to certain social factors which apply specifically to the aged who need help. Special legislation, the provisions of the National Assistance act already cited. Special provision for housing. Special medical services. Special financial provision, that is, pensions. And the general observation that when people need help because of their age, the need arises from a condition that is permanent, irreversible, and rather widespread. There is also the matter of sheer force of numbers which puts this problem in its own class. Why, indeed, does the National Old People's Welfare Council exist at all? Why not just the National Welfare Council? Yet if you care to raise the point of difference in the Council's offices or the Ministry of Health, you'll be solemnly assured that the elderly are really no different frOm anyone else. We are, they-say, all human. So we are, but in the face of. this welfare business, that's about as much help as saying that a man is as old as be feels.

To recognise how particular a group'' the aged are, and especially those who are in need of care and attention, is not to isolate them from society. They are in effect largely isolated already, and the pious wheezes only cloud the issue. BY simply recognising what the special characteris- tics of the aged-in-need are, one can more easilY fit them in among the other groups of which society is composed. Pretending that they are not a special group has gone a good way toward achieving exactly the opposite. The elderly in need of care and attention are still officiallY lumped in with the down-and-outs, the orphans, the ex-prisoners, the lame, the halt, the blind, the homeless and the mad. The Human Garbage Club still has its charter.

There are signs of at least a de facto recogni- tion of the aged-in-need as a special group. The list of services for them is long—local authority and voluntary housing, but not enough of it— meals on wheels, also not enough—grants for research, but insufficient means of converting the results into national policy—day centres, increased pensions, short stay homes, day homes for the aged, clubs, holidays, boarding-out schemes, training for those who work with the old, and on and on and on. But always a rueful echo: whatever the service is, it doesn't fully meet the need, or the elderly are not consulted• or there is a long waiting list, or more is needed, or the workers are badly paid, or there are gaps' or it's a drop in the bucket.

All this indicates rather strongly that some sort of comprehensive government-sponsored inquiry into the situation of the elderly is called for. This week Peter Townsend suggested that such an inquiry might usefully cover the follow- ing points:

Some attempt to establish what the maxi- mum demand on visiting services will be. There has been no general enquiry into visiting services.

Whether the aged mentally confused should be housed with the sane. No such enquiry was made to justify the recent fashion of shifting patients irons mental homes into hostels.

An attempt to establish how fragmented the services for the elderly are in different areas, and how the resultant vagueness of responsi- bility has impaired the services. For example, a look at after-care for elderly patients discharged from hospital. No one in particular seems to be responsible for following them up and seeing that they'rd all right.

Any suggestion of national inquiries will undoubtedly be met at ministry level with the reply that each locality is quite different from ,every other locality. Since they are so varied, it is argued, one can't usefully approach them on a national plane. But in fact nothing has been done to establish whether,, or not all these places do have common. factors which could make a

national .policy for the aged-in-need a feasible proposition.

The rapidly increasing size of this specific Welfare problem makes it difficult to understand why no such attempt has been made or is planned. One is handed the simple assumption

that no local authority has anything in common with any other,, and cant pis. In fact there is no

evidence of that. There can't be any evidence, since no national effort has been made to collect it. And of course, until the elderly are recognised as a particular group in the welfare scheme, there is officially nothing to study and nothing to collect.

One is told that `it is not government policy to concentrate responsibility for the elderly under one head,' not even in a department of a ministry. The most logical reason for that would seem to be the terrible embarrassment or nervous break- down which the head might suffer in trying to organise the present tangle of services. It all resembles a mob of honest and good-hearted People, some enthusiastic, some indifferent and some just so-so. They are trying, more or less, to shovel away a great pile of sand which is rapidly increasing in size. Some are using shovels. Some are using teaspOons, some are flicking at the sand With their fingers, some are using colanders, sc'rne are sort of blowing at the sand, and some are trying to scoop it up with pitchforks. The foreman stands to one side, politely murmuring that shovels are a good thing and that those With pitchforks, teaspoons and so on might Consider a revised assessment of their tools. Every-one agrees on broad principles such as 'it's a good idea to move the sand.' They also agree that sand is no different from any sort of dirt. After all, they say, it's all earth, isn't it? Clay, schinay. Soil, schntoll. Big rocks, little rocks, hat the hell? What's sand if it isn't little rocks? And, adds the foreman darkly, each little rock is different.

A joke? Ah, if only it were! Actually it looks like a waiting game, and as the song says, the °Id haven't got time for that.