When 79-year-old Ghulam Bibi* was left at a home for the elderly in Karachi, she didn’t realise that she would soon become a “sinner”. At the understaffed facility where she resides, there aren’t enough caregivers to swiftly deal with all her needs and her age-related incontinence often resulted in soiled clothes. “I was the sort of person who would never miss a single time’s prayer,” she said, “and now I can hardly ever offer my namaz. I’m a sinner now,” she lamented. 

Ghulam Bibi’s case is hardly uncommon, discovered Samina Vertejee, assistant professor at Aga Khan University School of Nursing and Midwifery (SONAM). In her almost three-decade career as a public health nurse, she has spent nearly 15 years in the field of geriatric care and can recount many an incident.  She has witnessed senior citizens being slapped for not following instructions, denied food and drink to put off bathroom visits and deprived of simple pleasures like a haircut or groomed eyebrows. 

The elderly are mistreated at home by their own kin too — “a phenomenon that cuts across all socioeconomic groups,” Samina goes on to observe. She recalls another old age home resident with a heartbreaking story. Due to tensions at home with her daughter-in-law, Rehana* was left to live at a home for the elderly by her son. She missed her family terribly. “I don’t like to live here but if I go home I will be beaten,” she told Samina. 

Elder abuse can take many forms and is defined by the United Nations as "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person".

However, it is an oft-ignored issue all around the world, including Pakistan.

This is surprising given the fact that Pakistan is a signatory to the Madrid International Plan of Action on Aging (MIPAA) 2002, which emphasises the need to include ageing in all developmental policies. The same need is further reemphasised in the United Nations’ Sustainable Development Goal 3 — “Ensure healthy lives and promote well-being for all at all ages” — that clearly identifies older people as an integral part of international development. Even Universal Declaration of Human Rights (UDHR) stresses that “everyone” is entitled to the rights enshrined in the document. Despite all the pledges, the elderly are deprived in our society.

“People don’t seem to realise that the needs of senior citizens are different. They need you to communicate with them with patience, because their listening and comprehension skills have weakened; they need to be handled with care because they are frail and their physical capacities have deteriorated. Their caregivers owe them dignified and age-appropriate care.” 

The need for awareness about empathetic healthcare acquires a sense of urgency when taking into account the changing demographics of Pakistan. At present, according to the UN Department of Social and Economic Affairs’ World Population Prospects: The 2015 Revision, Key Findings and Advance Tables, people over the age of 60 years and 80 years constituted 6.6 per cent and 0.6 per cent of Pakistan’s population respectively in 2015; however, these figures are expected to more than double to 12.9 per cent and 1.3 per cent in 2050 and 26.2 per cent and 5.3 per cent in 2100. 

To make this ideal of empathetic care a reality, Samina has been engaged in a mix of research and educational endeavors’ at Aga Khan University.

In 2011, Samina and her colleagues at SONAM began developing a course that was reviewed by national and international experts called ‘Care of Elderly’ — the first of its kind in Pakistan. The course offered, as an elective, in 2013 to bachelor-level nursing students, aimed to highlight the need for specialised geriatric care in the current healthcare system. 

In the ‘Care of Elderly’ course, students must spend 54 hours on clinical placement in old age homes, among other healthcare settings and communities.

“When we first offered the course, we saw that students were nervous. They didn’t know how to take care of elderly people! But as time passed, they felt empowered. They were better equipped to handle even the elderly people they had at home.”

The course is now regularly offered as a summer elective to undergraduate nursing students at SONAM. 

However, increasing the number of skilled caretakers is just one part of the solution. 

In the research she’s conducted at Aga Khan University, Samina has found other deficiencies including the lack of standardisation of geriatric care practices in old age homes. 

She reveals, “Some provide good facilities such as doctors and nurses and age-appropriate diet; but others severely deprive its occupants. At present, there is no legislation that provides checks and balances on the nature of services and the credentials of institutions and their caregivers. Hardly any of them are licensed; many are running under the license of an NGO.” 

“Fifteen years ago, I knew of only two old age homes in Karachi. Now, I know of at least 30 and there must be more. The owners are not even health care providers,” she adds.

To help resolve such issues, Samina has also been an active campaigner for senior citizen rights at the legislative level, having worked with Mrs. Shireen Rahimtoola’s Senior Citizen Welfare Trust and her own NGO Senior Citizens Caregiver Organisation (SCCO) for the approval of the Sindh Senior Citizens Welfare Bill 2014. After three years of meetings with various lawmakers and parliamentarians, the efforts bore fruit when the Bill was approved as Sindh Senior Citizens Welfare Act 2014 in front of her eyes in the Sindh Assembly on April 29, 2016. 

As SCCO’s Vice President, Samina is trying to combine the disparate efforts of various NGOs engaged in senior citizen rights into a collaborative, concerted effort. She is one of many advocates for the elderly who have contributed to the creation of a group called the Network for Ageing Rights Activists (NARA)** to eliminate the duplication of efforts and to form a larger group that could have a bigger impact.   

It will take a big push to get the Act implemented because Samina observes a lack of political will for the issue. “Pakistan is right now still struggling with diseases of poverty. It’s said that we are allocating resources where they are needed the most — in improving infant mortality rate, maternal mortality rate. We want to prove ourselves as a good country by focusing on improving more visible metrics, but geriatric care is also an area that needs to be looked at.”

Perhaps this is the reason why Samina’s dream project is a community-integrated model of elderly care. 

“I envision a project where the elderly can be taken care of within the community by the community. For example, in a community of 5,000 people, 500 may be aged 60 years and above. We can identify volunteers who can schedule visits to people who need assistance at certain times. And for people who need continuous support, they can be moved to a home within their community, so they don’t lose their ties and can still visit their neighbourhood sites.”

The project is currently in its conceptual stage, but Samina is hopeful that this will reduce the dislocation the elderly feel and enhance the quality of care they receive.

“We may be a resource-constrained society, but we are also one of the most generous in the world. I feel we can move beyond what our government’s resources can do for health. Our civil society can and must do much more,” she concludes. 

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*Identities changed to protect privacy.