The Elderly Providing Care for the Elderly in ... - Duncker & Humblot

Sociologus, Volume 64, Issue 1, p. 29 – 52 Duncker & Humblot, Berlin

The Elderly Providing Care for the Elderly in Tanzania and Indonesia: Making ‘Elder to Elder’ Care Visible By Peter van Eeuwijk* Abstract The provision of care for the elderly by the elderly does not attract much attention in either Tanzania or Indonesia, as communities consider this care arrangement to be incompatible with normative values. Differences in care arrangements and practices are observable through ethnographic comparison; nevertheless, in both contexts most elderly caregivers develop considerable social agency in the context of problematic changes in health to their aged care recipients. In critical health moments, recourse to younger family and kin members as normative carers takes place, in Tanzania through pressure from kin, and in Indonesia through negotiation among kin. Non-kin care by old persons is encountered rarely or never in both study regions. However, different forms of care institutions managed by elderly principals are becoming increasingly important, not least as gatekeepers for new concepts of care for the elderly. Keywords: Care for the elderly, older people as caregivers, Tanzania, Indonesia

1. Introduction: Older Persons as Caregivers This article1 describes how elderly persons provide care for the aged in Tanzania and Indonesia and how this practice is affecting old age in both countries.2 From an older person’s perspective, growing old and * Dr. Peter van Eeuwijk, Institute of Social Anthropology, University of Basel, Department of Social and Cultural Anthropology, University of Zurich, and Swiss Tropical and Public Health Institute, University of Basel, Switzerland; University of Basel, Institute of Social Anthropology, Münsterplatz 19, CH-4051 Basel, Switzerland · E-Mail: [email protected] 1 An initial version of this article was presented at the international workshop, ‘Rethinking Care: Anthropological Perspectives on Life Courses, Kin Work and their Trans-Local Entanglements’, held at the International Research Centre, ‘Work and the Life Cycle in Global History’ (re:work) at the Humboldt University, Berlin, in December 2012. 2 The research projects in Indonesia (‘Growing Old in the City: Health Transition among the Elderly in North Sulawesi, Indonesia’, 2000 – 2004; head: Peter van Sociologus 64 (2014) 1

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old age are significantly shaped by the provision or lack of care when they find themselves in need of support (Eeuwijk 2006b). Normative attitudes in most societies assign this task to the younger generations,3 and in particular to women (Sokolovsky 2009: 6 – 9). This picture is embedded in idealized imaginations based on, for example, kinship ties, filial piety and generational responsibility, gender roles, family solidarity, religious and moral obligations, and professional ethics. Yet, real care practices in our studies from Tanzania and Indonesia provide ample evidence that care is also being provided by other elderly, mainly older women. However, the practice of care being provided by older persons for the frail and aged does not meet social expectations and does not comply with prevailing normative attitudes. The phenomenon of older persons acting as senior caregivers is no longer unusual in the social sciences. Many studies of ageing, health and care in low- and middle-income countries show that, due to major societal transformations such as demographic and epidemiologic transitions, social transformations, cultural changes, migration and urbanization, older people are increasingly assuming the role of major caregivers in their households. In particular, research on HIV / AIDS in Sub-Saharan Africa (e.g., Casale 2011; Klerk 2011; Ogunmefun et al. 2011) and Southeast Asia (e.g., Knodel and Saengtienchai 2002; Knodel 2012) has revealed this important shift in care practice from older care recipient to aged caregiver with regard to HIV-infected spouses, AIDSdiseased children and orphaned grandchildren. For some time already non-governmental and multilateral organizations have emphasized the growing importance of older persons as caregivers in Asian, African and Latin American households and have asked for greater recognition and support (HelpAge International 2004, 2007, 2012; WHO 2002). However, the role of older people as major caregivers, particularly for other older individuals, in both informal and formal care arrangements represents a new, yet underestimated and under-investigated issue in social science research on ageing, health and care.4

Eeuwijk) and Tanzania (‘From “Cure to Care” among the Elderly: Old-age Vulnerability in Tanzania’, 2008 – 2011; head: Peter van Eeuwijk) were funded by the Swiss National Science Foundation (SNSF). This institution is also funding the current research project in Tanzania (‘Ageing, Agency and Health in Urbanizing Tanzania’, 2012 – 2015; head: Brigit Obrist; in Dar es Salaam, Zanzibar, Arusha, Moshi). Jana Gerold, Vendelin T. Simon, Andrea Grolimund and Sandra Staudacher in Tanzania, and Benedictus Lampus, Henky Loho, Heny Pratiknjo, Elisabeth Sumarauw and Welly Mamosey in Indonesia, have collected the empirical data together with the project leaders. 3 On the conceptualization of ‘generation’ in social anthropology, see Alber and Häberlein (2010). Sociologus 64 (2014) 1

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To make ‘elder for elder’ care more visible, this article examines three facets of this particular care phenomenon: A. Varieties of care arrangements with older persons as major caregivers. B. Care activities carried out by these older carers and the burden they carry. C. Extended care arrangements in critical health moments. This contribution highlights the interface between care practices provided and received by older individuals and their influence on the well-being of the elderly. The agentic extension of social space in problematic caregiving moments is seen to reaffirm relations of kinship and generation (Eeuwijk 2011; Gerold 2013).

2. Research Setting and Methodology This study refers to the elderly and their social and physical environments at different research sites in Indonesia and Tanzania.5 The Indonesian cases comprise three diverse cities in the province of North Sulawesi, namely Manado, a busy and trendy provincial capital on the Celebes Sea, the economic and political centre of this province, and an important hub in north-eastern Indonesia; Tomohon, a large district capital on a fertile volcanic plateau and the centre of the Protestant Minahasa Church; and Tahuna, a small regency capital and lively rural coastal town on volcanic Sangihe Besar Island that is also the centre of the Protestant Sangihe-Talaud Church. The participants in the Indonesian study, who came from seven urban political communities, represent mainly the two dominant regional ethnic groups (Christian Minahasa and Christian Sangihe), Moslem inhabitants with different ethnic backgrounds from different Moslem regions in the then province of North Sulawesi, such as the districts of Gorontalo and Bolaang-Mongondow, and some Buddhist Chinese households (Eeuwijk 2003, 2006b, 2012). The Tanzanian sites are the country’s biggest city, Dar es Sal-

4 Most of the literature on old persons and support deals with living arrangements, not care arrangements, and does not specify age and gender. For example, the category ‘living with spouse’ does not allow age or gender to be identified, nor who is the carer and who the care recipient. 5 The percentage of total population above sixty in Indonesia was 8.5% and in Tanzania 4.9% in 2012 (2050: Indonesia 25.5%, Tanzania 6.4%); life expectancy at birth (2012 – 2015) is 68 years for men and 72 years for women in Indonesia, and 58 years for men and 60 years for women in Tanzania (HelpAge International 2012).

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aam, and more particularly Mbagala Ward in Temeke Municipality, a once ‘planned settlement’ with slum dwellings but with a low level of public infrastructure today; the rural, booming town of Ikwiriri, close to Rufiji River and the strategic Mkapa Bridge on the main road to Mozambique; and the remote village of Bumba, with bad road access by motorbike to three hamlets in Rufiji District (Coast Region). The overwhelming majority of people in the Tanzanian cases are Moslem Warufiji (‘people from Rufiji’). This also applies to multi-ethnic and multireligious Dar es Salaam by reason of its research setting, namely the desire to investigate the rural-urban ties of this ethnic group exclusively (Gerold 2012, 2013; Simon 2012). In both countries the research setting included different societal levels: (1) a community study of important public and private actors in the field of older persons’ health and care; (2) a household study of 151 households in Tanzania and 152 households in Indonesia respectively; and (3) an age cohort study of 76 older participants in Tanzania and 75 in Indonesia respectively, selected from the household sample. We added a tracer illness study in Indonesia of 42 elderly persons suffering from chronic illness selected from the cohort sample. The main criteria for participation in the study were a) a household with at least one old person, and b) this person being sixty years old or older. The lower age limit for inclusion (sixty years) corresponds to the official definition of the respective Indonesian and Tanzanian ‘National Ageing Policy’ (Department of Social Affairs 2003; Ministry of Labour, Youth Development and Sports 2003). The study teams applied this numerical bar to inclusion for methodological reasons, although they were fully aware of its limitations and shortcomings in ageing studies with a social science perspective (Featherstone and Hepworth 2009; Sokolovsky 2009; Fry 2010). Sampling methods comprised the techniques of simple random sampling in Tanzania, stratified random sampling in Indonesia, and purposive sampling in both the Indonesian tracer illness study and with regard to key persons in both countries. The studies in both sites used a combination of qualitative techniques (in-depth interviews, focusgroup discussions, direct observation and case studies), quantitative research methods (e.g., statistics and structured questionnaires) and documentary tools (e.g., photo documentation) (Eeuwijk 2003, 2006a, 2012; Gerold 2012; Simon 2012). In Indonesia the field team consisted of four social anthropologists and two public health specialists, while in Tanzania the field team comprised three social anthropologists. Data analysis was conducted with reference to both main codes and sub-codes using the qualitative data analysis software MAXQDA. The empirical data for this paper derive from the household study in both countries Sociologus 64 (2014) 1


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and are complemented by findings from the community and age cohort study. The present author’s comparisons are thus based on empirical data and findings provided by two separate study teams in two different contexts. The ethnographic comparison describes differences and similarities with reference to one single phenomenon, namely, care of the elderly provided by the elderly in the two different settings of Tanzania and Indonesia. Nonetheless the aim of author’s reflections on ‘disjunctive comparison’ (Lazar 2012) is not to postulate a common, homologous justification, but to offer views on this phenomenon as embedded differently in each of the two contexts.

3. Care and Old-age Care Contemporary concepts of ‘care’ in the social sciences encompass not only medical interventions and technical operations from a ‘narrow’ perspective, but also emotional-affective assistance, social support, material and financial backing, everyday help in the household, religious relief and physical aid in a much broader sense (Eeuwijk 2011). Geest (2002: 7), a medical anthropologist, delineates ‘care’ as both ‘emotional and technical / practical. The latter refers to carrying out concrete activities for others who may not be able to do them alone. […] “Care” also has an emotional meaning, it expresses concern, dedication, and attachment.’ Mol (2008: 1), a medical sociologist, describes care as ‘activities such as washing, feeding or dressing wounds, that are done to make daily life more bearable’. From the social work perspective, Leira (1994: 187) relates ‘care’ ‘to affection as well as to activity and to love as well as to labor’. Finally, the social gerontologist Phillips and his colleagues (2010: 42) describe ‘care’ simply as ‘providing or receiving assistance in a supportive manner’. Multiple ambiguities such as emotional / technical, caregiving / care receiving, affection / work and burden / relief characterize and shape these notions of care. Keeping these intrinsic ambiguities, overlaps and polarizations in mind, the concept of ‘elderly care’ thus epitomizes how, in oscillating between cultural representations, moral claims, structural principles and practical necessities, a society is concerned with its vulnerable older persons and how it supports them when they are in need (Eeuwijk 2006b, 2007, 2011; Tronto 2009). The understanding of ‘care’ as both a relational and a temporal concept has shaped the study setting of our research on ‘ageing, health, and care’ in both Tanzania and Indonesia. The narrow perspective described above clarifies care as interpersonal assistance in the probleSociologus 64 (2014) 1

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matic (health) moments of an individual (A). The broader view explains care as a social and cultural practice and therefore as a relational phenomenon (B): being related to a (frail) person who is in need of some kind of support. Both these perspectives have framed the three dimensions of ‘elder to elder’ care in this paper: care as social practice and relational occurrence in everyday life (B) refers to compositions of care arrangements with older persons as major caregivers and care recipients (presented in Table 1), and to care activities provided by older caregivers for aged persons (Table 2), while care as concrete interference (A) relates to the extension of care arrangements in problematic (health) situations and, as a consequence, to the expansion of social space, including new and ‘old’ relations of kinship (Table 3). The above ‘broad’ view of care – i.e., its emotional and moral meanings – includes ‘the two basic movements of human existence: towards the other and towards the future’ (Kleinman and Geest 2009: 159 – 160). The first dimension perceives care as a strictly relational phenomenon: one becomes a caregiver because one is in relationship with a person who is in need of care (Kleinman 2009). In this context, ‘to take care of somebody’ assumes that an individual interacts with other persons and that he or she has to be present among them (i.e., biological and social relatedness). No individual was born a caregiver, as Kleinman (2009: 293) emphasizes: ‘[O]ut of practices comes caregiving. We are caregivers because we practise caregiving.’ Care practice occurs within and through social interactions. The second dimension of care (‘towards the future’) implies intentionality with regard to the future, or better, an attitude of expectation and hope towards ‘the others’, as well as oneself. In this respect, ‘care’ is a basic projection of humans into the future – for instance, an instrument of precautions and / or of prevision, though shaped by past and present experiences. 4. ‘Elder to Elder’ Care Arrangements in Tanzania and Indonesia Intergenerational care support is considered to be the ideal form of caregiving and receiving in our study communities in both Tanzania and Indonesia. When asked the reasons for this, the great majority of elderly Warufiji refer to cultural values that include the duty of generational reciprocity (i.e., parents caring for their young children and at a later time children caring for their aged parents) or to religious rules pointing to particular surah in the Koran; all aged Minahasa and Sangihe (in Indonesia) emphasise that this norm of intergenerational care is already embedded in their unwritten rules of conduct (adat) and thus serves as customary practice. However, in both study areas almost Sociologus 64 (2014) 1


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three quarters of elderly people added the statement that care support by an older wife for her aged husband – and thus ‘replacing’ inter- by intragenerational care – fully complies with the above rules and norms because it follows established gender roles. Table 1 reveals that the ‘caregiving older wife–care-receiving older husband’ arrangement is by far the most frequently found arrangement for elderly care in both sites. It is therefore accepted to a large extent, and social blame is put neither on the children (who do not care) nor on the older person (who cares), except in critical health moments (see Table 3). In particular the remaining types of elderly care arrangement (see Table 1) still provoke some disapproving reactions from community members: ‘You see, she did not raise their children well, now they return the like’ (Tanzania). Examples of disapproving statements from the community regarding ‘elder to elder’ care include the following: ‘He did nothing for his daughter and her husband, this is the result now: no care from them’ (Indonesia); and ‘The son does not support his old parents because they were too greedy for money when he worked abroad’ (Tanzania). Older persons (as caregivers or care receivers) comment on their situation in different ways: ‘I don’t want my demanding daughter-in-law to take care of me – I trust in my older sister!’ (Indonesia), ‘My son and daughter do not have a good relationship with me; ultimately, we failed to discuss their care for me; my older sister supports me’ (Tanzania); and ‘People may think that I am not a sociable person, but I am sick of asking my children for more support – my housemaid cares for me now’ (Indonesia). These examples illustrate that these particular types of ‘elder to elder’ care may lead to displeasing and offensive social reactions and to a lower degree of social appreciation towards these older persons. ‘Elder to elder’ care arrangements are not a ‘new’ and so far unknown form of care support, neither in Tanzania nor in Indonesia. Yet, the frequency of this model of ‘elder to elder’ care, its average duration and the intensity of work it implies in respect of an older person acting as the major carer for an aged person in a family have changed over time, not least due to the demographic, epidemiological and social transformations in the study communities over the last twenty years.6 Nevertheless, the numerical bar for inclusion in our study of sixty years or over does not imply that younger people in either study setting experience care – that is, caring for an elderly person – as any less tiresome, exhausting and stressful. The burdens of care and its many hardships 6 The author has observed major transformations in the composition of care arrangements in both study contexts over the last twenty years. In the past, the reactions of family, kin and community members to ‘elder to elder’ care were significantly more judgemental and disapproving than they are today.


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are felt by all ages, but they exert a different effect on the elderly than on the young. Moreover, (non-)compliance with care obligations (e.g., younger children supporting their elderly parents) does not depend on a numerical age limit but more particularly on the quality of social, cultural, emotional and psychological relations between the members of each generation. The chronological limit we have applied in our study is thus not a crucial and determining criterion for complying with norms and rules (such as filial piety and care obligations), nor for providing (or failing to provide) the elderly with care. The compositions of care arrangements which include exclusively persons sixty or older as major carers and care recipients (see Table 1) represent the scope of social space and distance, as well as of inter- and intra-generational and gendered engagement in ‘elder to elder’ care. The Tanzanian sample comprises 151 households in which 43 primary old caregivers are looking after aged persons (28.5 per cent). The Indonesian study includes 152 households and shows 55 major old care providers of elderly individuals (36.5 per cent). In almost every third household, major care work for an old frail person is thus being provided by an older woman or man. Yet, the study shows a much higher number of these ‘elder to elder’ households in the rural Rufiji area (Tanzania) and the small archipelagic town of Tahuna (Indonesia), owing to the out-migration of younger people, than in highly urban Dar es Salaam, urban Manado or Tomohon, where many households consist only of a single person aged sixty or above and younger children taking care of them (Eeuwijk 2006b; Gerold 2012; Simon 2012). Intra-generational care relations – i.e., providing care to members of the same generation – are strongly marked by the ‘caregiving wife–care receiving husband’ arrangement (see Table 1). This particular spouse relationship – not surprisingly, due to the greater life expectancy of women and their being younger than their husbands – is undeniably the most convenient type of care arrangement for two old persons aged sixty years and above in both the Tanzanian and Indonesian study sites, corresponding with cultural expectations as regards the duties of care related to the roles of husband and wife respectively. The Tanzanian Warufiji stress that an elderly wife should provide the best possible service to her aged husband, which is what he is indeed entitled to. Older Indonesian Minahasa and Sangihe husbands emphasize that their elderly wives should preferably act as the ‘main coordinators of care’ in their households. Care provision by an aged husband for his equally aged wife occurs infrequently, particularly in the rural Rufiji area and remote Tahuna. Generally, old husbands in our Tanzanian and Indonesian studies consider extensive care support for a frail old wife voluntary and optional.7 These situations are caused mainly by children who Sociologus 64 (2014) 1


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are unwilling or unable to provide care for their elderly mothers, or else it results from failed negotiations between parents and their children and children-in-law. Care provision among elderly siblings – in most cases widowed, divorced (mainly in Tanzania), or unmarried aged persons – is not uncommon and occurs primarily between siblings of the same sex (see Table 1). In a few Moslem families in rural Rufiji, more than one old wife provides care for her frail elderly husband. Some Indonesian intra-generational care arrangements represent a ‘modern’ care work feature: care is provided by older non-kin such as housemaids or, in a very few cases, by female neighbours. Paid care work involving old housemaids is encountered exclusively in wealthy Buddhist Chinese families in urbanized Manado. Table 1 Care Arrangements with Oder Persons (60+) as Primary Caregivers for Aged Care Recipients (60+) in Tanzania and Indonesia (Arrangements in Italics Show Men’s Major Involvement in Caregiving; Number in Brackets Indicates Frequency of Each Type of Care Arrangement)

Tanzania (n=43)

Indonesia (n=55)

Intra-generational elderly care:

Intra-generational elderly care:

Wife > husband (14) 1st + 2nd wife > husband (3) Younger sister > older sister (1) Older sister > younger brother (1) Sister-in-law > brother’s sister (1)

Wife > husband (32) Older sister > younger sister (3) Housemaid > old women (3) Housemaid > old man (1) Housemaid + older sister > younger brother (1) Female neighbours > widower (1) Husband > wife (9) Wife + brother-in-law > husband (1)

Husband > wife (4) Older brother > younger brother (1) Inter-generational elderly care: Old daughter > mother (3) Old daughter-in-law > mother-inlaw (1) Old granddaughter > grandmother (1) Mother > old daughter (2) Old son > mother (1) Old son > father (1) Old male cousin > father’s sister (1)

Inter-generational elderly care: Old daughter > father (1) Old daughter > mother + father (1) Daughter-in-law > mother-in-law (1) Son-in-law > mother-in-law (1)

Table 1 continued next page

7 Warufiji gender norms stipulate that an old husband is only obliged to provide financial support and basic household resources for his wife.


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Table 1 continued Tanzania (n=43)

Indonesia (n=55)

Inter- and intra-generational elderly care: Wife > husband + her mother (1) Wife > mother-in-law + husband (1) Old granddaughter + sisters-in-law > grandmother (2) Mother + old daughter > daughter (1) Old daughter + father / husband > mother (2) Old son + mother / wife > father (1)

Inter- and intra-generational elderly care: None

Intergenerational care arrangements for the elderly are much less frequent due to the natural boundary of life with regard to the care recipient. In most cases, an ageing daughter (sixty years or older) provides care for a very old mother (see Table 1). Whereas in the Tanzania study we typically find this care arrangement among same-sex family members, ageing daughters in our Indonesian sites also care for their very old fathers. In both the Tanzanian and Indonesian studies, care provided by older children-in-law (mainly daughters-in-law) is considered as being prone to tensions and therefore not really approved of by core kin. Exceptions of inter-generational care of the elderly include ageing granddaughters giving support to a very old grandmother or an old mother taking care of a frail elderly daughter. The combination of inter- and intra-generational elderly care in Tanzania usually comprises a very old spouse and an already old child (sixty years or older), both providing care for their old mother or father (see Table 1). Occasionally an older wife (together with a daughter) cares for her old husband and her even older mother, or two aged persons (e.g., an elderly daughter and her very old father) provide care to their frail old mother and wife, respectively. The Indonesian sites do not feature any combined inter- and intra-generational elderly care arrangements except in critical health moments. This compilation of elderly care arrangements shows a distinct gender differentiation (see in Table 1 the items in italics for men’s caregiving involvement). Most of the care relations mentioned include old women as major caregivers: many more old women provide care for aged men (and for old women, too) than the other way round. Except for the old housemaids in Chinese families in urban Manado, these care arrangements occur mainly among close relatives due to the intimate and sensitive nature of care practices. Sociologus 64 (2014) 1


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5. Main Care Activities in ‘Elder to Elder’ Care Arrangements and the Burden of Care In both the Tanzanian and Indonesian studies, the main care activities provided by older people for aged persons can be grouped into three major categories (see Table 2): (1) daily domestic work (Tanzania: A – H, Indonesia: A – E in Table 2); (2) activities related to frailty and illness (Tanzania: I – M, Indonesia: F – J); and (3) psycho-social counselling (Tanzania: N – Q, Indonesia: K – M). Financial issues were never mentioned in the context of these care activities, although older caregivers complain about the rising cost of care as an additional burden. One reason for this apparently contradictory attitude is the observed practice that financial matters (e.g., costs for medical visits, medication or special food) are not negotiated directly with the older care recipient and are therefore not part of the relationship of care. Moreover, as major caregivers, elderly Warufiji women state that their husbands or sons are fully responsible for the allocation of monetary resources and that this ‘struggle for money’ belongs to the duties of male family members. Many older Indonesian carers feel ashamed to mention financial hardship in connection with caregiving activities, particularly in front of a sick older person. Still, financial matters become a care burden because they strain the whole social environment involved in the caregiving. The Tanzanian sample displays more physical domestic activities, including farm work for procuring food, than the Indonesian sites (see Table 2). This is mainly due to the presence of the rural sites of Ikwiriri and Bumba in the Tanzanian study, where old caregivers are still engaged in basic domestic work such as fetching water, collecting firewood, or pounding grain. Urban Indonesia and urban Tanzania in our study sites do not feature many of these activities. For aged carers this work implies a sound physical and mental constitution. Moreover, the many daily routine activities inside and outside the house call for an appropriate daily schedule that does not neglect the care receiver’s needs (Eeuwijk 2007). To a large extent, health-related activities comprise actions inside the house (see Table 2). In both the Tanzanian and Indonesian studies, these practices focus on guarding and looking after a frail and sick older person, accompanying him / her to the bathroom, toilet, or bed, administering drugs and serving healthy food such as a diet. Very intimate activities such as dressing / undressing and bathing are only provided when an old person becomes physically and mentally dependent on his / her caregiver(s). Only very close kin carry out these sensitive chores – and, not surprisingly, they are strongly shaped by gender roles in both Sociologus 64 (2014) 1

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research areas (e.g., in Tanzania an elderly daughter cannot wash the body of her frail father or dress / undress him). Table 2 Main Care Activities Provided by Old Caregivers for Aged Care Recipients in Tanzania and Indonesia

Tanzania

Indonesia

A. Cooking / preparation of food and drink B. Fetching water (from outside the house) C. Bringing water to bathroom D. Collecting firewood E. Doing laundry F. Cleaning house / compound G. Pounding grain H. Going to shamba (field plot) and fetching field products, doing farm work I. Guarding an ill older person (when bedridden) J. Giving food / drinks K. Accompanying to toilet / bathroom L. Buying medicine M. Accompanying to hospital / healer N. Talking, gossiping, and socializing O. Consoling and encouraging P. Giving advice Q. Praying together

A. Cooking / preparation of food and drink B. Shopping in the market C. Doing laundry D. Cleaning house / compound E. Bringing water to bathroom F. Administering drugs G. Accompanying to toilet / bathroom H. Dressing / undressing I. Bathing J. Preparing for bed K. Massaging L. Consoling and entertaining M. Giving advice

Activities as regards psycho-social counselling are very much overlooked in most care studies. However, Table 2 shows that old caregivers provide very important emotional support and social assistance to aged persons in their households. The mutual sharing of longstanding, similar life experiences and related attitudes make the elderly carer a reliable and sympathetic counsellor in what may be a difficult situation for an elderly care recipient. Talking, socializing, but also consoling, encouraging and praying together are very meaningful care activities that maintain and strengthen the emotional condition of someone who is old, frail and ailing. Massaging is an exclusively Indonesian practice, being provided as a preventive bodily measure, but it also has psychological effects. A massage creates social proximity between the two indiSociologus 64 (2014) 1


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viduals and emotional relief due to the active engagement of the carer on behalf of the elderly care recipient. In our 98 study households in Tanzania and Indonesia, where primary old caregivers look after aged persons, the great majority of elderly carers are willing and able to provide even stressful and exhausting care for their frail and aged kin. Yet, their support has its limitations in terms of quantity as well as quality. Older caregivers in our study sites in both countries identified the following five general burdens of care: (1) physical burden; (2) economic burden;8 (3) social burden; (4) psychological burden; and (5) infrastructure burden. Particularly older female caregivers expect more substantial support from their family members in mitigating their care burdens. In many cases in our studies in Tanzania and Indonesia it is even the family that exerts pressure on and creates unease towards old caregivers, not at least by spreading rumours that tarnish the social and moral reputation of an aged carer. The high burden of care can strain, even rupture kin relations, for instance, between a caring elderly daughter and her younger sisters and brothers-in-law, or even between children and a caregiving older mother. 6. Extending Care Arrangements in Critical Health Moments In critical health moments an old carer may realize that his or her aged care recipient has fallen seriously ill or is gradually weakening from old age, and that wide-ranging reactions at the household level are about to change the lives of the old caregiver, the old care recipient and their family. Critical health moments can be triggered by specific problematic health events which include not only a sudden illness (i.e., bone fracture, organ failure) that demands an immediate and adequate response, but also slow, degenerative processes that last for months and years and are monitored by the old caregiver and other family members. One important agentic practice in critical health moments is the social extension of an existing, but currently overstrained ‘elder to elder’ care arrangement. This means that new members are mobilized by the elderly caregiver and become part (physically, financially, materially, and / or emotionally) of the given care arrangement. This ability of elderly caregivers to mobilize members of visible and invisible social networks (family, wider kin group, or neighbourhood) for care provi8 Elderly better-off people in our study, such as wealthy Chinese shopkeepers in urban Indonesia and the well-to-do urban middle class or retired civil servants in Tanzania, do not explicitly emphasize the financial burden caused by caregiving.


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sion represents their social agency and resilience in such serious care situations. The compilation in Table 3 reveals that in most care arrangement extensions children, grandchildren, children-in-law and siblings join the existing ‘elder to elder’ care relationship. In only a few cases do nonkin persons become additional caregivers, for example, in Tanzania house tenants and neighbours, and in Indonesia house tenants, housemaids and neighbours. Close relatives are again the main caregivers to join in. Given this fact, children, grandchildren and children-in-law are the family members who most frequently lend support in problematic health situations to older wives providing care for their aged sick husbands (see Table 3). The gender perspective shows that in (patrilineal) Tanzania many more male relatives (e.g., son, grandson, son-in-law, brother) are mobilized to support the household in coping with the suffering old person than in (bilateral and to some extent patrilineal) Indonesia, where it is again female kin who are the predominant caregivers in a new care arrangement. Nonetheless, in both study sites these younger male and female carers who join in the arrangement primarily contribute three care activities: (1) financial support (e.g., buying food, paying treatment costs);9 (2) physical support (e.g., cleaning floors, doing kitchen work); and (3) social support (e.g., socializing, consoling, giving advice). Yet, the Indonesian list shows seven cases of care arrangements for which no additional support at all could be mobilized. In these cases the situation was caused either by longstanding, fierce family conflicts (mainly in Buddhist Chinese families in Manado), leading to irreversible social exclusion, or by long physical and social absence from the original place of residence (e.g., as a seaman, soldier, or overseas workers from Tomohon and Tahuna). The large variety of extended care arrangements in the Indonesian study attracts attention. In Tanzania the Warufiji descent system chiefly adjusts care obligations through the paternal side of the family and thus limits the optionality of possible care settings: It is a father’s sons and daughters who are primarily called on to provide additional care for their aged parents.10 Grandchildren (of the father’s children) may join these new care arrangements. Marrying a younger, healthy second or third wife is a viable option to respond to a high burden of care experienced by the first and oldest wife, but it is not popular in Warufiji communities. The bilateral Minahasa and Sangihe in Indone9 This includes remittances (e.g., from children working in other cities in the country or abroad), bank orders sent through cell phones and cash transfers. 10 It is not uncommon for an older Warufiji couple to have children by a different father or mother.



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Table 3 Extended Care Arrangements in Critical Health Moments in Tanzania and Indonesia in Households with a Major Older Caregiver (Terms in Italics Show the Person(s) who Provide(s) Additional Care Support)

Tanzania

Indonesia nd

rd

1) Wife > husband + 2 / 3 wife 2) Wife > husband + all (common) children 3) Wife > husband + son 4) Wife > husband + daughter 5) Wife > husband + his children + son-in-law (husband of his daughter) 6) Wife > husband + son + daughter + grandchildren (of his son) 7) Wife > husband + her brother 8) Wife > husband + neighbours 9) Wife > husband + house tenants 10) Old daughter > mother + grandson (of son / brother) 11) Old sister > Old brother + his grandson 12) Younger sister > older sister + children (of both sisters) + grandchildren (of younger sister) 13) Husband > wife + daughter + his nephew 14) Husband > wife + her sisters 15) Old son > mother + his grandson 16) Old son > father + daughter-inlaw (old son’s wife)

1) Wife > husband + all daughters 2) Wife > husband + granddaughter (of their daughter) 3) Wife > husband + daughters + sisters (of wife) 4) Wife > husband + his nephew 5) Wife > husband + all daughters + granddaughters (of these daughters) 6) Wife > husband + daughters + all daughters-in-law 7) Wife > husband + daughter + granddaughters (of this daughter and a son) + daughters-in-law 8) Wife > husband + all children + housemaid (of elderly couple) 9) Wife > husband + daughter + female tenant (of elderly couple) 10) Wife > husband + daughter + daughter-in-law + sisters (of elderly wife and husband) + housemaid (of elderly couple) + neighbours 11) Wife > husband + daughter + granddaughter (of this daughter) + daughter-in-law + his sisters + housemaid (of elderly couple) 12) Wife > husband + daughter + granddaughter (of this daughter) + daughter-in-law + housemaid (of elderly couple) 13) Wife > husband + housemaid + neighbours 14) Wife + brother-in-law > husband + children (of elderly couple) 15) Husband > wife + daughter + granddaughters (of this daughter and a son) + daughters-in-law 16) Husband > wife + daughters + siblings (from husband’s and wife’s side) 17) Older sister > younger sister + children (from this younger sister) Table continued next page


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Table 3 continued Tanzania

Indonesia 18) Older sister > younger sister + children (from both sisters) + children-in-law 19) Old daughter > father + her grandchildren + his children-inlaw (1 daughter- and 1 son-inlaw) 20) Old daughter > mother + father + children + siblings (from mother’s and father’s side) 21) Daughter-in-law > mother-inlaw + children (of daughter-inlaw) + children-in-law (of motherin-law) 22) Son-in-law > mother-in-law + his children + his grandchildren 23) Housemaid > old woman + sisters (of old woman) + nephew (of old woman) 24) Housemaid > old woman + children (of old woman) 25) Housemaid > old man + his daughters 26) Housemaid + older sister > younger brother + older siblings (of this sister and brother) 27) Female neighbours > widower + (newly-married) wife + children (from both sides) 28) No additional care support: 7 households

sia make ample use of both lineages, as well as of the wider kinship and even non-kin relations. However, this wide variation in care arrangements also reveals instability in the sense that such extended care provisions are subject to regularly recurring negotiations, sometimes on a daily basis (e.g., regarding food preparation or money allocation for medication), or off and on monthly (e.g., providing accommodation for an elderly mother). A large number of different younger caregivers joining a new care arrangement may thus guarantee a certain care security for both the old carer and his / her aged care receiver.



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7. Non-Kin Care, Eldercare, and Institutions This section sheds light on a fairly underestimated issue in both countries, namely institutions where old persons provide care support for other old, mostly frail individuals. In our Tanzanian and Indonesian cases, the chairperson, director, or principal of these institutions is also an elderly woman or man, a fact that has an immediate, positive impact in terms of credibility and solidarity between them in their roles as elderly provider (or manager) and aged user (client, member or participant). Our research has identified the following institutions in the Tanzanian and Indonesian study sites, which are managed by old persons, whose members are older people, and whose major task is to provide care and support for aged persons: 1. Clubs: an ‘older male club’ with informal membership where old men gather regularly at the town market to sell dried tobacco or fish; beside providing mutual support in critical health moments, they enjoy discussing; three to four older men constitute the club’s informal ‘management’ (cases: Ikwiriri, Tahuna). 2. Associations: supported by church institutions, government departments, or better-off elderly individuals, such ‘associations of seniors’ run by older leaders provide income-generating activities, church services for the elderly, leisure time activities, home visits for social and psychological support, financial assistance when ill, and medical check-up meetings (cases: Ikwiriri, Dar es Salaam, Manado, Tomohon). 3. Self-help groups: an elderly widow ‘activist’ has founded a self-help group with / for older widows and widowers who take care of their orphaned grandchildren; they organize income-generating activities and regular meetings for socializing; they enjoy donations from partners from abroad (cases: Dar es Salaam, Arusha). 4. Non-government organizations (NGOs): a couple of older men manage an official non-government organization with the help of funds and material donations supplied by foreign sponsors; they visit their elderly sick patients at home on a daily basis, which includes administering drugs (cases: Dar es Salaam, Arusha, Moshi, Tomohon). 5. Care institutions for the elderly: an old people’s home or nursing home run by faith-based organizations (e.g., Catholic order of nuns, Seventh Day Adventists, Pentecostal Church, Moslem brotherhood, Buddhist temple congregation) or by the government managed by older persons; the aged residents live there on a permanent basis and Sociologus 64 (2014) 1

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are looked after according to their physical and mental condition (cases: Dar es Salaam, Zanzibar, Manado, Tomohon). Care work in the above-stated institutions is mainly carried out by older women and without remuneration (except for elderly care institutions [5] and partly for NGOs [4]). Christian charity, a sense of belonging along with feelings of solidarity among persons of the same age (and also same sex), a professional ethic of service, past personal experiences, activism triggered by notions of gender or age inequality, and also the opportunity to pursue ‘ethically correct’ income-generation in old age are the main reasons and motivations for the volunteers to provide care support in these five institutions. For aged people in acute or long-term need of care, these institutions and their elderly principals play an increasingly crucial role on the basis of their complementary nature in terms of social, emotional, economic and health aid. They represent an active form of care, providing part of ‘community support’, and thus non-kin care, by expanding the ‘social space of care’ (including care practices) for both caregivers and care recipients, but still without transgressing the cultural boundaries of elderly care. However, in neither the Tanzanian nor the Indonesian study sites can they fully replace family and kin as the core care providers. More than a few older caregivers in these institutions have developed valuable ‘soft skills’ such as fund-raising, proposal-writing, public relation abilities and worldwide networking through new social media. Their initiatives are aimed not least at the global ‘care market’, where care activities serving elderly frail persons in Sub-Saharan Africa and Southeast Asia sell increasingly well. The modernistic developmental era in the 1980s and 1990s in Tanzania and Indonesia brought new ideas, new actors, and the rationality of modern project and programme management. A number of the care-providing institutions described above have become formal ‘care projects’ or ‘health programmes’ funded by national and international private or public donors. ‘Project course instruments’ (e.g., planning, monitoring, evaluation and accountability) represent new values in care work for local elderly caregivers as the managers of such institutions. The commodification of care work transforms this non-kin elderly care itself into a commodity represented in such ‘carescapes’. At the same time they form entry points for new, flexible and thus rapidly changing scientific, political and lay concepts with regard to ageing, health and care. Our study came across the explicit elderly care concepts of ‘home care’, ‘healthy ageing’ and ‘ageing in place’ introduced and applied by associations, non-government organizations and elderly care institutions, as well as different welfare schemes (e.g., a kind of health insurance for older persons with chronic illnesses developed by non-government orSociologus 64 (2014) 1


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ganizations), the application of new technology (e.g., the use of cell phones for the regular monitoring of elderly diabetics and tuberculosis patients at home managed by self-help groups and associations), and public health approaches, such as a regime of monthly biomedical check-ups for the elderly by self-help groups, associations and nongovernmental organizations. Many of these ideas and practices are modelled on concepts generated by foreign donors, that is, in the Tanzanian study the European Development Fund or a US-based non-governmental organization run by American seniors, and in the Indonesian study, the Japan International Cooperation Agency and the Vereinte Evangelische Mission among others. Otherwise they were obtained through meetings, visits or oral communication with national partners (e.g., Good Samaritans, HelpAge Tanzania, The Foundation for Civil Society in Tanzania; e.g., Yayasan Emong Lansia, Lembaga Kordinasi Kesejahteraan Sosial in Indonesia), or gained through the Internet. On the one hand, these inter-institutional global connections and the inherent production, exchange and transfer of concepts, ideas, imaginations and experiences of care work are shaping and challenging new forms of inter- and intra-generational care relations on a local basis. On the other hand, a new quality of exposure is resulting from these elderly care institutions: the increasing dependence on project funding and foreign donors is creating new forms of susceptibility for the older caregivers and aged care recipients attached to these care institutions.

8. Discussion The quality and quantity of care provided by old persons for the aged in their households is widely underestimated and often simply overlooked in ageing studies. Two main reasons for this attitude emerge from this research. First, by and large this ‘elder to elder’ care does not comply with social norms and cultural rules in our Tanzanian and Indonesian study sites; hence, it does not conform to the expected practice of care relations and does not comply with conventional images of care for the elderly, and as a result it is not made fully visible either. Secondly, older caregivers themselves display an increased degree of multiple vulnerabilities (e.g., towards the burdens of care, sickness, frailty, disability or impoverishment) and are considered to be less resilient (for instance, physically, mentally, or economically). In all the cultural settings of this study – rural and urban, patrilineal Moslem Tanzania, and urban Christian and Moslem, bilateral Indonesia, including patrilineal Buddhist Chinese – discourses on intergenerational relations, care support and kinship obligations are characterized by the high expectations of old persons in need of care in stating that their Sociologus 64 (2014) 1

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children have to provide care support. This image and imagination is a distinct expression of complying with the normative cultural requirements of filial piety. The attitude of intergenerational indebtedness does not tally with real care arrangements: in about one third of our study households in Tanzania and Indonesia an old person provides major care for another aged individual (sixty years and older). A rigid conclusion would argue that intergenerational relations and parent-child negotiations have completely failed in these families (particularly in rural Tanzania and among Indonesian Buddhist Chinese), as has, implicitly, the notion of the family as the central care provider. Yet, everyday practice shows that explicit social blame is put neither on old (caring) parents nor on their (non-caring) children. Old Indonesian caregivers judge this ‘elder to elder’ care arrangement to be a necessary, but pragmatic adjustment to a rapidly changing urban context, even though they tacitly miss the much praised norm of filial reciprocity. In the Tanzanian study site older caregivers rate this care arrangement as an inconvenient occurrence to be accepted under the circumstances – but implicitly it goes against the conventions. This ‘idealized morality’ (Utomo 2002: 226) of wanted children’s care support has partially failed, but it does not undermine the lived system of moral norms, social structure and religious values. In fact, the strong assistance of younger children is no longer expected – except in critical health moments – and ‘elder to elder’ care practices have become increasingly well established. This is particularly the case in both remote out-migration sites, that is, Bumba village in Tanzania and Tahuna in Indonesia, where a majority of older persons cohabitate with their spouse only. Two interacting major fields shape this ‘elder to elder’ care in our studies in Tanzania and Indonesia: (A) norms, rules, conventions and values (e.g., filial piety, kinship obligation, gender relation, religious standards, moral principles, underlying social imagery), structuring and framing ageing and care relations in regulating and controlling ways, and acting as general cultural guidance when the elderly are in need of care and as a potent social backing for their claims to care support; and (B) social agency, enabling older carers to mediate options for practice and enhancing their capacity to act, for instance, through negotiation, refusal and divorce (in Tanzania), extending care arrangements, using urban-rural resources (in Tanzania), converting social capital into ‘actions’, involving elderly care institutions and using new technologies (e.g., cell phones). Nonetheless, some non-agentic practices such as an elderly wife’s passivity and strict refusal to give care contravene the conventions of care provision and can lead to harsh reactions. We may conclude that the most frequent intra-generational Sociologus 64 (2014) 1


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form of elderly care in our Tanzanian and Indonesian research sites, namely an elderly wife providing care for her old husband, complies essentially with prevailing gender norms, even though it is not an intergenerational care arrangement. Moreover, the new joint care arrangements in the case of critical health moments draw upon well-accepted conventions such as kinship obligations, children’s indebtedness and inter-generational support, thus fully complying with cultural imaginations of care for the elderly. The case studies from Tanzania and Indonesia reveal that older carers responsible for elderly care recipients who are going through critical health moments can make the most of their social and cultural capital. They are able to reduce their own degree of susceptibility, for instance, by mobilizing younger kin members to participate in care work and to join a new ‘combined’ inter- and intra-generational care arrangement. These ‘changing webs of kinship’ (Alber et al. 2010: 43) have both weaknesses and strengths. The case of patrilineal Tanzania shows a rather restricted optionality with regard to creating new extended care arrangements, and the prospect of expanding social spaces for care in critical health moments is somewhat limited by norms and values. In our study in bilateral and partly patrilineal Indonesia, care practices shaped by generational norms and gender rules are usually subject to negotiation and thus more fragile. In contrast, the same restrictive rules and values in Warufiji communities entitle an older woman or man in need of care to claim effective support from his or her spouse, children and younger siblings – an important form of reassurance, as well as a last means of pressure among Warufiji elderly on their family and kinship. In Indonesian Minahasa and Sangihe families, this kind of social prompting finds little acceptance among either parents and children, ultimately disrupting this inter-generational relationship. The many care-providing institutions in our study sites in Tanzania and Indonesia, in particular those social bodies where older persons take care of the frail and elderly, chiefly provide complementary care support for needy aged persons. In a few cases they act as a last resort in respect of care for socially and economically neglected older persons. Both the common indicators of institutional identification, such as the same age, religion, sex, marital status, locality, illness or care burden, and the peer ‘management’ lead to a high degree of credibility and reliability from an old care recipient’s perspective. The evolution of many of these ‘elder to elder’ care institutions into projects and programmes of international health – thus following its own developmental rationality – increasingly turns these institutions into not only a meaningful link in global care chains, but also important non-kin ‘partners’ for families and households when it comes to elderly care. They become acSociologus 64 (2014) 1

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tive ‘gatekeepers’ for the transfer of new models and images of care practices. Moreover, through their local appropriation of transnational flows, and in their capacity as globally linked projects, these ‘elder to elder’ care institutions act as a vital platform – in the sense of a ‘carescape’ developing some form of shared care citizenship and ‘care-based sociality’ among older caregivers and care recipients – and are thus having an increasing impact on ageing in Tanzania and Indonesia.

Acknowledgement The author would like to thank Nigel Stephenson for his thoughtful proofreading and comments and Barbara Heer (University of Basel) for her insightful information on comparative ethnography based on her research project ‘Space, Difference and the Everyday: A Comparative Ethnography of Neighbourhoods in Maputo and Johannesburg’ (2010 – 2015). My thanks also go to the two anonymous reviewers and the editors for their constructive and valuable comments.

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