We all know what’s coming. Everywhere in the developed world, populations are greying. The media are full of stories about the surge in the numbers of the elderly within the next 20 years, while governments have been pushing the age of retirement entitlements upward. Most of the spotlight has been on the new greybeards themselves—the Baby Boomers in North America and Australia, the somewhat smaller postwar “boomlets” elsewhere—and not on the other side of the approaching demographic flip. The elderly will almost double their current share of national populations—not just because they are so many, but because their descendants are so few.
More than half the world’s population—now lives in societies where the fertility rate has been dropping, like a stone in some places, for decades. Among demographers, the prevailing narrative for this sea change in human affairs talks of economic development finished off by cultural change. As countries grow wealthier and more urban, with higher levels of education for women, as well as men, women naturally wish to have fewer children; add in access to safe and effective means to that end—contraception and abortion—and that’s precisely what they do.
True enough, but not the whole truth, argues Harvard demographer Michael Teitelbaum, co-author (with Yale historian Jay Winter) of The Global Spread of Fertility Decline. At the core of the change, Teitelbaum believes, lies the rational belief of young adults—especially the highly educated, those most aware of the weak points in their society’s institutions—that they live in “risk societies.” The risks they see can reach to the apocalyptic (will there be another Chernobyl, another 9/11, how many more Lac-Mégantics?) to macroeconomic pessimism (can today’s social welfare entitlements last?) to individual concerns(will we ever be able to own a house?). Marriage- and child-aversion are among their risk-management strategies.
And they will be for the foreseeable future. “If governments wanted to have low fertility rates, what they would do—if they understood the phenomena—is what they have actually done without intending to lower fertility, which is to make life hard for young adults,” says Teitelbaum. “If you make things hard for young men and women, especially women between 20 and 35, by stretching out their educations, by raising the risk that they face of not being able to find a job or becoming unemployed soon after, stagnating wages, allowing housing prices to rise rapidly, they will have very few children. It’s not as if anybody has designed these phenomena to cause young adults to delay child-bearing—nobody planned it—but they happened, and they’ve happened with a vengeance, in some places.”
We worry about our declining birth rates or we celebrate them, fret over who will pay for our pensions and health care, or see a hopeful slowdown in the consumption of the planet’s finite resources. But we have not yet come to grips with what they will mean in our lives, as the largest generation in North American history moves into its final years.
The coming crisis in elder care won’t be just about the sheer number of aging Boomers. It will also be a story about lives lived longer but with chronic conditions, especially those that diminish cognitive capacity; of rapidly changing female roles—indeed, in some parts of the world, of missing women; of the burgeoning new world of commercial old-age-care services; of a globalized, in-demand yet ill-paid workforce; of a sometimes desperate search for technological solutions, including robot caregivers; and, above all, like Sherlock Holmes’s dog who didn’t bark in the night, it will be a tale coloured throughout by those not in it, the absent children.
The Baby Boom generation simply had fewer children than their parents did—far fewer in many countries—and those kids were encouraged to move out into the world in the way Boomers themselves did. Many of the consequences were positive, especially at first, but others, more problematic, are only beginning to work their way through the Boomers’ lifespans: as they age they are going to find themselves in many cases without adult children nearby to look after them. And that will matter. Some 80 per cent of all care—for children, the disabled and the elderly—in the U.S. is unpaid work provided by family members, says Jody Gastfriend, the vice-president of senior care at Care.com, a giant American care provider and online resource that opened operations in Canada last year. The value of that elder care, in dementia cases alone, a recent study by the RAND Corporation estimated, was at least $50 billion annually in the U.S., as measured by income foregone by family members, and as high as $106 billion when measured by what a family would have paid professional caregivers. The situation is much the same in Canada, where those over 65 now comprise 15 per cent of the population; most have several children. By 2030, the over-65s will become a quarter of the population, most with notably fewer children.
Elder care is already straining the budget and the lives of millions. Consider Janet Hillen, 69, of Georgetown, Ont., outside Toronto, and her care for her stubbornly independent 90-year-old mother, who still lives alone in her house in nearby Mississauga. “I’m the eldest daughter and a retired nurse; it falls to me. In fact, near the end of my career, I worked in geriatric nursing, which has proved helpful in navigating the health care system.” Hillen feels she is always battling the system on two fronts—“I fought with doctors over my father’s driving after he became an absolute menace on the roads” (he died with Alzheimer’s at age 96)—and with her mother, who sometimes sabotages what Hillen is trying to do for her. “I’ve lost track of how many visiting health care workers she’s fired.”
At one point, after finding her mother was essentially living on coffee and rye bread, Hillen arranged for Meals on Wheels. But her mother cancelled the service without telling her daughter. “I thought I’d pop an eye vein, I was so upset when I found out. ‘What are you eating?’ I yelled.” Compounding everything is Hillen’s loving understanding of her mother’s position. Of course, she doesn’t want to leave her house. “She loves her garden. She can take you through it. The whole thing is a story: This plant came from an uncle’s grave, this one was a gift from an aunt.” Recently, after a very bad winter—Hillen suspects her mother hurt her wrist shovelling snow off her steps—Hillen’s mother has agreed to move to a seniors apartment, although she occasionally denies agreeing to any such thing, and refuses to sell the house “in case she doesn’t like it, and wants to move back.”
Now consider how fortunate, relatively speaking, Hillen is. Her mother’s health, both physical and mental, is good, and she herself is a retired health care worker wise to the system’s quirks. Hillen does not have a conflict between work and family because she, too, is retired; her mother was only 21 when Janet was born. The Baby Boomers are known as the “sandwich generation” because they are squeezed between dependent children and needy parents; one reason the kids are still at home is that delayed child-bearing is a hallmark of the Boomer generation. Finances are not an issue for Hillen’s mother: She grew up on a Manitoba farm between the world wars, when thrifty self-reliance was more necessity than virtue. One reason she cancelled Meals on Wheels was that the cost—$6 a meal—scandalized her. Boomers, on the whole, have exhibited an entirely different attitude toward money than their Depression-era parents.
In any event, because of the wartime service of Hillen’s father, Veterans Affairs pays for his widow’s lawn mowing and snow clearance. In America, where a far higher proportion of the population has been militarily involved since the Second World War, and where the social safety net is flimsier, Pentagon support will prove crucial for many.
Care.com’s Gastfriend remarks how her family was paying for a secure seniors’ home for her father, who suffered from dementia for a decade before his death, before they realized the scale of his military benefits. Those cut the cost of his home from $9,000 a month to $900. But mass Canadian engagement with the armed forces ended a half-century ago. In short, Hillen’s situation will be statistically ever less likely as time goes by.
It’s not even the norm now. In 2007, Statistics Canada reported that more than half of those caring for elderly relatives confessed to feelings of exhaustion and depression from the stress of juggling children, parents and career. Gastfriend asks rhetorically, “What do you do if you get a phone call: Your mother, the primary caregiver for your father, who has dementia, has fallen and broken a bone and is in hospital, and they are two hours away and you have a crucial presentation the next day?” And, the demographic trends suggest, there is no other child any nearer?
You could call Care.com. Members, for a monthly fee, are entitled to an emergency response plan that would see appropriate health care workers immediately dispatched. They would still have to be paid, but clients are saved the stress of having to find them. And Care.com, where the child-care division remains the largest—although Gastfriend expects it to be soon eclipsed by her seniors’ department—is only one of numerous emerging elder-care services.
Right At Home, a 300-office American corporation, has just opened its first Canadian franchise, in the affluent Toronto-area city of Burlington, aiming for a profitable niche between public services and what well-off seniors might want. Mark Goliger, COO of Right At Home Canada, expects to open another dozen franchises by year’s end. “We’re between the rock of a demographic bubble and an economic hard place,” he says. “People are living longer with chronic issues, children are fewer, and can’t keep up with the unpaid labour. What government does well is in-home medical care. What it falls short on is non-medical daily living, like laundry and shopping help.” Right At Home offers across-the-board services, “whatever you need,” says Goliger, from driving to appointments to personal care—bathing, dispensing medication, even administering insulin—to nursing. Some 60 per cent of its clients are seniors themselves; the other 40 per cent are adult children, mostly looking for personal support workers. Parents are frequently in denial about those kinds of needs, Goliger says. “They hide incontinence, sores, lack of eating.”
Driving is one of the most practical and emotionally laden issues in elder care, the sharpest single line between independent seniors and needy aged. Hendrik Hartog, a 64-year-old Princeton historian drawn to the problem of family conflict over old-age care partly from personal experience, notes that cars are the key factor in the historical novelty of older generations living lives independent of their children. He’d be overjoyed, he adds, to see the Alberta-based seniors’ service Driving Miss Daisy open in New Jersey. His own parents are dead, but, “for my wife, with two parents in their 90s, finding drivers for them is a central part of her life.”
Jenny Viau, 31, who started up Miss Daisy’s sole Toronto franchise in January, echoes Hartog’s thoughts. “The loss of the ability to drive is crushing. Sometimes, after the adult children phone me—usually in relief, because hiring me is far cheaper than them constantly taking time off work—they call me back later to say mom or dad doesn’t think they need us.” Or, she says, the older generation is upset that the children have outsourced their family duty to strangers. Viau has had a couple of male clients, both who soon quit, unhappy at being driven by a woman. Now she has a few female regulars. She’s driven one to the family cottage, and another on visits to her husband’s grave. With one client, there is no actual driving—Viau sits and talks with her. “There are fewer and fewer young people to help them,” she says. Or even to visit.
And if there are fewer volunteers and no time, elder care is going to cost money—lots of it. Everyone in the seniors’ services business is upfront about costs. Goliger is particularly adamant that North America is not financially ready for what is to come. “I tell anybody who listens to start saving now, because the government won’t be able to pay. People need to know now what they will need, from savings to insurance, and start paying into plans.” Not all the costs will be paid from individuals’ pockets, Goliger and Gastfriend concur. “More and more insurance companies will offer elder-care plans,” Goliger says, while Gastfriend adds that Care.com’s plans “have a lot of traction, as a potential job benefit, with employers seeking solutions for distracted, depressed employees, many of them in senior positions.”
The people who are increasingly doing, for pay, what traditional family caregivers can no longer do, are several economic classes away from those who are their ultimate employers. “We charge clients $22 to $30 an hour, because we don’t do a huge amount of nursing,” says Goliger, noting that sort of medical care can rise to $60 an hour. “And we still get a lot of sticker shock in Canada, because Canadians think government should pay.” Those rates allow Right At Home to pay its employees from $11.50 to $15 an hour, “a competitive wage that provides ordinary margins.” The hours and the expenditures add up, says Gastfriend, making them “really significant for many families, so there’s strong resistance to paying caregivers more.”
Given the low pay and the high demand, elder care is becoming what child care has been for decades: an occupational niche where the actual physical labour is performed by what historian Hartog calls “a global migratory workforce, usually without labour entitlements or protection.” (The Philippines, which derives 10 per cent of its GDP from remittances sent back by citizens working abroad, is now the caregiver factory to the world, sending thousands of young women to Europe, North America, parts of east Asia and the rich Arab Gulf states to care for children and, increasingly, their grandparents.) For Hartog, the workforce is a morally troubling issue and one of the emerging system’s weak points. Here in North America, Gastfriend acknowledges, an in-demand field that offers little incentive for workers to commit to it is inherently unstable: “There’s been talk of unionization, and there’s already a shortage of workers in some rural areas.”
Elder care, like child care, has always been what academics now call a “gendered” duty, with the hands-on burden traditionally falling on daughters or daughters-in-law. That’s still true today, even if it now consists of navigating bureaucracies or supervising another woman from half the world away, whether women resist that duty or freely accept it—witness Janet Hillen’s matter-of-fact “I’m the eldest daughter.” Although the new scarcity of female offspring and in-laws will be important in low-fertility North America and Europe, it will be especially crucial in east Asia. Nowhere else will that aspect of the elder-care story play out more against the other factors involved: the dwindling family, the longer-living elderly, the associated costs and the uncertainty as to where the new workforce will come from.
In 1971, when the birth rate in Canada was already at the replacement rate of just over two children per woman, east Asia’s overall number was 5.6 and South Korea’s 4.5. Forty years later, while Canada has drifted downward to 1.7, South Korea has cratered to 1.4, and Hong Kong, seemingly seeking to become the world’s first childless state, is at a staggering 0.9. The falling birth rate is a bedrock part of what’s known as “compressed modernity” in east Asia: What North America had trouble enough digesting in more than a century has utterly transformed the region, especially South Korea, in a single generation.
Elderly populations are ballooning everywhere. In Japan, which entered low fertility decades before its neighbours, it is already a full quarter of the nation. Caring for them, traditionally a daughter-in-law’s task in Confucian societies, would have been difficult, even if the birth rate had dropped in a sexually neutral way. But there are millions more young men than women, especially in China and South Korea, because of the region’s strong preference for sons, often achieved, in recent decades, through the selective abortion of female fetuses.
“In all these societies, strong traditions of filial piety continue,” says University of Toronto sociologist Ito Peng, “but they fall on fewer children and they bump up against competing ideas of modern freedom. Women, in particular, don’t want to be tied down, especially not to be at their in-laws’ beck and call.” (Asian women, of course, are not alone in that reaction. The parent-child bond rarely runs as strongly from child to parent as it does the other way, says Hartog: “No one in the modern world thinks that caring for old parents is what their life’s work is. At best, it’s a distraction; at worst, a burden.”)
Japan spent most of the ’90s in denial, says Peng, but finally grasped the financial nettle in 1997. The country established a huge new tax, almost five per cent of income, to pay for elder care. In 2008, continues Peng, South Korea, knowing that it would be in Japan’s position in 20 years, “decided to be pre-emptive,” and did the same. The funding is crucial, especially in Korea, because the demand for care workers is matched by resistance to foreign help. “The Koreans established special visas for Chinese of Korean descent, even if they didn’t speak Korean well. There’s some 300,000 in the country now, many, especially the women, working in elder care,” Peng says. Even so, as in Japan—which tried much the same with Latin Americans of Japanese descent in the 1980s—foreigners, no matter what their bloodlines, are not seen in Japan and Korea as the first choice in elder care. “That’s why,” Peng says, “they’re working so hard on the robotics.”
The Japanese government is stepping up its support for robotics in the face of the worker shortage. (The official explanation for high turnover and vacancies is “back pain” brought on by helping the elderly from bed to wheelchair, although some officials allow that “low pay” is a factor.) In April, Tokyo handed out $25 million to 24 companies to develop “nursing-care robot equipment.” Carmaker Toyota’s project is designed to help the elderly move about, while Sekisui Hometechno Co. is working on a mobile flush toilet; other companies are tasked with tracking those who wander off. The 40-cm Paro therapy bot, which resembles a baby seal, now offers recreational therapy in one old-age home experiment: It plays games and quizzes, and sings and dances with the residents. “He knows everything very well. I learned a lot from him,” Tsugie Nakanishi, 88, told the Japan Times.
The Japanese are not alone in placing their faith (and hopes) in technology. Walter Greenleaf, a division head at the Stanford Center on Longevity, thinks technology offers the best grounds for optimistic thinking. “Robots, iPad apps that remind the elderly of important matters [such as their meds], the driverless cars that have been on the horizon for some years” will all help keep the aged independent. “Let’s hope,” adds Greenleaf, 56, “that, by the time we’re in our 90s, the car technology will be there.”
Greenleaf needs to keep his outlook on the sunny side, because the department he heads at the longevity centre—the mind division—has little good news to report. The number of people with Alzheimer’s and other forms of dementia in North America is projected to double within 30 years, and strike perhaps a third of the elderly. “We’ve had a lot of breakthroughs—in cardiology, in cancer—but not in those diseases that affect our cognitive abilities.” With labour and money in short supply, even technology won’t solve the coming problems by itself. There will need to be cultural changes, too, notes Greenleaf, who cites time-banking plans in which healthy seniors can build “credit” by helping the older and more frail. An organizer keeps track of how many hours of help such volunteers provide, credit hours they can draw upon during their own time of need.
And then there are those siblings. Boomers may be short on kids but, by definition, they abound in sibs. Watching them reunite to care for an aging parent, sometimes after decades apart and often with unresolved childhood issues, experts ﬁnd no middle ground in their relations. After financial worries, Gastfriend says, the greatest source of stress in elder care is sibling discord among adult children, something that has a deleterious effect on the health and longevity of everyone involved, parent and children alike. On the other hand, sibling accord brings nothing but health benefits to everyone. In short, Boomers should patch things up with their brothers and sisters. They’re going to need each other.