Vikram Patel writes | The need of the hour: ASHA for elderly

I can see the impact of increasing life expectancy from very close quarters: My father is now 89 years old, an age which would have been inconceivable at the time of our Independence when life expectancy was around 30 years. Certainly, in the highly privileged social class to which my family belongs, such an advanced age is no longer exceptional. Indeed, as India celebrates her own coming of age, turning 75 this year, the population projections suggest that the country is already home to 30 million persons who are 75 or older. I will reach this milestone in 2039. By that time, the World Population Prospects estimates there will be nearly 100 million persons older than 75 in India. This is a staggering number of people who are no longer in the workforce and who are at a much greater risk to be living with and dying from a chronic, often disabling, health condition.

I have watched, with great sadness, my father struggle with such a disabling condition over the past decade, which has left him largely bed-ridden and in need of full-time care. Thanks to his wealth, he has been able to pay for three full-time caregivers, a family physician who reviews his health every week at home, a physiotherapist who visits three times a week and, when there is a crisis, a hospital physician who will arrange admission to a tony city hospital at short notice. Like my mother who finally passed away after a long struggle with multiple health conditions some years ago, my father has been able to survive to this ripe old age primarily because he has been able to pay vast sums of money, out of pocket, for the diverse types of care he needs. I will never forget one occasion when my mother had survived yet another acute medical crisis, and her care-giver remarked to me that no one in her village would have lived as long as my mother had with her health conditions.

Mercifully though, neither of my parents was afflicted by dementia. No illness can be more devastating for the person, and their families, than dementia, a condition associated with ageing and resulting from progressive degeneration of the brain. Dementia poses an enormous burden of care as one gradually loses the ability to care for oneself and to think, plan and behave in a rational way. A recent paper which synthesised 20 epidemiological studies, including nearly 90,000 individuals from India, reported that about 8 per cent of the population over 75 was afflicted by this condition. One estimate from the reputed Alzheimer’s Association suggests that the country is already home to 4 million people with dementia; this number will grow dramatically in the future as the population ages. The final, most difficult, stage of dementia, by which time the person will need round-the-clock care for even the simplest activities of daily living, can linger for up to three years. Where once our multi-generational families could be relied upon for care-giving (of course, this was typically done by the women in the family), the population transition has been accompanied by dramatic changes in the family structure and an increasing proportion of the elderly will live only with their elderly spouse or alone.

A hugely important question in the light of the population projections is the country’s preparedness for the exponentially increasing needs for care for people with chronic conditions like dementia. Such care typically extends well beyond the narrowly defined clinical treatment of specific diseases and encompasses a range of services — in particular, primary care which integrates care for diverse health conditions, home-based nursing, palliative care and rehabilitation. A short answer is virtually none at all. There is no comprehensive, community-based, care system for elders. Families have to make their own arrangements through out-of-pocket payments for each service which is needed. Even if the family has the money, the services needed are not even available in most places. This means the vast majority of elders in India are left to their own devices. In a country where civic infrastructure, such as public transport, is insensitive to the needs of persons with different abilities, many elders with disabling conditions will be trapped in their homes, eking out the last years of their lives alone and forgotten by society.

There is a solution which is in plain sight. One of India’s singular contributions to population health has been its deployment of frontline workers to deliver promotive and preventive healthcare. India’s celebrated Accredited Social Health Activists (ASHAs) have been singularly responsible not only for the dramatic reductions in maternal and infant mortality contributing to our increased life expectancy, but also to achieving our impressive Covid vaccination coverage. They were deservedly awarded the WHO Director-General’s Global Health Leaders Award in May for their outstanding contribution towards protecting and promoting health. The ASHA program is a template for building a community-based workforce, anchored in the large and growing network of government Health and Wellness Centres across the country, to support the diverse health and social care needs for elders. As the population projections show, India is rich with human resources who are young and looking for work and we could simultaneously address two population challenges by empowering working-age adults who are jobless in the service of elders. What elders need, most of all, is a caring and compassionate person, with the requisite skills, to accompany them on the last journey of their lives. India’s ingenuity in leveraging community resources to address her complex problems presents a unique opportunity to make her a country which offers a hopeful future for both her elderly and her young people.

The writer is The Pershing Square Professor of Global Health at Harvard Medical School