PB April 2009 Aging: The Indian Context Swami Narasimhananda hy do you want a housing loan at this age? What happened to your present house?' The volley of questions from the chief personnel officer of the hospital where Shila worked fell on her stoic face. 'I cannot help you if you do not give me the details,' said the chief sternly, much to the embarrassment of Shila, whose colleagues were standing nearby. Shila could not contain herself any longer and started sobbing, 'Sir, yesterday night my two sons drove me and my husband out of the house we had built out of our hard-earned savings. We have a small plot of land nearby. We spent the night there in a shed. Our sons now want us to build another house and be away from their lives. This is why I need the loan badly. What is my fault? I brought up my two sons and daughter as best I could. Neither I nor my husband have had any formal education. Both of us worked hard day and night, got our daughter married, and procured decent employments for both our sons, paying heavy bribes. We were happy thinking we could enjoy our retirement. But today we are deserted. Looking after one's parents has been the family tradition for generations. What happened to my children? Or was anything wrong with our parenting? Is this the result of our bad karma? What does the Lord want from us?' The chief had no answers to these questions, but he hastened to process Shila's loan application.1 Aging in Early Vedic Times The questions posed by Shila compel us to review the status of the aged in Indian society across the centuries. Were the old in India always in such predicament, or are we witnessing a shift in priorities in Indian society? To understand the evolution of traditions associated with old age we need to overview Indian society from Vedic times. A survey of Vedic literature shows us that old age was welcomed by contemporary society.2 With the threat of natural calamities and diseases always lurking around, humans of the Vedic period often had their lives cut short well before the cherished hundred years. Given the limitations of the social structure, civic amenities, and knowledge resources then available, illnesses and injuries-from wars, accidents, or animals and insects-took a heavy toll on human lives. Everyone prayed that they might live longer, get to see their grandchildren, and encounter death only late in life. Their desire was to live life to its fullness, enjoy the company of successive generations of offspring, and die only after attaining old age. Old age was glorified and the sick were blessed that they could recover and die natural deaths. A prayer on behalf of a sick person in the Atharva Veda says, 'Unto old age do I commit you [the sick]; unto old age do I instigate you; may old age, excellent, conduct you; let the other deaths go away, which they call the remaining hundred.' 3 Thus old age was something to be happy about and not a cause of fear, since to live longer was considered a sign of vitality and good luck rather than a struggle with the failing body and its associated ailments. We find various poetic descriptions of aging and subsequent death in the Vedas. The Shatapatha Brahmana portrays old age as a boatman carrying individual souls to the other shore, death.4 A hymn from the Atharva Veda presents death as something that permeates every moment of human life. This hymn seeks blessings for the journey from birth to old age and death.5 People in the early Vedic era spent their relatively short lives in education and subsequent management of their households. Retirement was 'W PB April 2009274 Prabuddha Bharata26 not contemplated, and it was considered a great blessing if one could continue living well after one's children were married. The system of four ashramas- including retirement into contemplative life in the forest, Vanaprastha, and Sannyasa-seems to have become regularized only in Upanishadic times and may have signified a longer and more stable life. From Yearning to Fear With advances in general social life and medical knowledge, the late Vedic era probably witnessed an increase in the average lifespan, which is reflected in the development of the system of four ashramas. The average human life was now divided into the phases of education, Brahmacharya, household life, Grihastha, retirement to forest for contemplation, Vanaprastha, and renunciation or mendicancy, Sannyasa. Ethical manuals called Dharmashastras laid down the general rules for each phase of life. Old age, which in early Vedic times was a period to be cherished, became an object of fear-a reminder of the impermanence of life and the ensuing death. It was the time for renouncing worldly life and preparing for death. Ways to eliminate or transcend the suffering caused by old age were actively sought. Meditation and contemplation on the ephemeral nature of the world were prescribed, even as endeavours to overcome aging and death were undertaken. The people of the post-Vedic era were advised to spend the latter part of their lives in retirement, contemplating the perishable nature of the human body, and pursuing the higher realities of life. At this stage a person was expected to renounce enjoyments of the senses. The materialists were of course of the view that one should enjoy sense pleasures till one is exhausted. However, the famous anecdote of King Yayati occurring in the Bhagavata emphasizes the futility of this approach and asserts that the best way to transcend the snares of the senses is to give up sense enjoyment.6 According to Vedic tradition the body is an instrument that the soul uses to exhaust its karma, the accumulated effects of past actions. Birth and death are but phases in the perpetual transmigratory cycle of existence. This cycle of birth and death goes on till all the effects of an individual soul's actions are exhausted or neutralized. This is liberation, moksha. The Shvetashvatara Upanishad says, 'The individual soul, considering itself and the Controller as different, revolves in this great Wheel of Brahman that is the sustenance of all and the place of dissolution of all. When (one's Self ) is adored as (identified with) It (the Supreme), one attains immortality.'7 The realization of one's identity with the Power driving this cycle is the way to come out of it. Hence, according to the Vedas, aging and death do not mean the decay or destruction of the embodied entity. In the natural process of evolution of thought, post-Vedic society gave a pronounced metaphysical dimension to aging. In a sense, the average human being started fearing the arrival of old age, in contrast to the yearning for it seen in the early Vedic era. Early Geriatric Medicine in India Aging has several aspects to it. It is most manifest in the physical body. Ayurveda is a traditional system of medicine which deals with the general principles of human health from a typically Indian viewpoint. Therefore, to get an idea of the ancient Indian understanding of aging we need to go through the principal Ayurvedic texts: Charaka Samhita and Sushruta Samhita. It is interesting to note that, several centuries prior to the development of modern medicine, these texts contained highly developed concepts of geriatrics harmoniously interwoven with Vedic metaphysical ideas. For instance, the idea that a soul gets embodied to exhaust the actions of past births is also found in Ayurvedic texts, which state that 'life is a productive and dynamic aggregate of sense organs, mind, body, and self, held together and maintained over a definite period of time by the power of karma performed in previous lives'.8 According to Ayurveda, the human body is supported and sustained by three humours which are derived from three basic elements: kapha, from 275PB April 2009 Aging: Th e Indian Context water; pitta, from fi re; and vata, from wind. Th ese humours originate from the food eaten, digested, and assimilated by us. Th e humours of the body have a macrocosmic dimension also, as detailed by Sushruta: 'Just as the moon, sun, and wind uphold the world by their action of release, absorption, and dissemination respectively, even so do kapha, pitta, and vata act with regard to the body.' 9 Th e balance or imbalance of these humours cause good or ill health respectively. Th ese humours are always changing, depending upon the person's activity and the environment lived in. Human beings are sustained by the nutrient fl uid produced by the action of the three humours, and this fl uid needs to be preserved with great care. Th e humours are responsible for both the physical and psychic health of an individual. Maintaining proper balance of these three humours was the major concern of health care in ancient times. However, aging was inevitable even then. Aging begins just aft er birth. Th e initial years of growth and development of the body camoufl age this aging process, which becomes manifest only when one starts to weaken physically. According to Charaka, aging is a gradual process and brings with it certain geriatric ailments which have no remedy. Th ese are to be taken as signs of impending death. Th e process of aging has been vividly described in Ayurvedic texts. According to Sushruta, 'aft er the age of seventy, with each passing day, the seven bodily elements, sense organs, energy, vitality, and enthusiasm undergo a signifi cant decline giving rise to wrinkled skin, grey hair, baldness, chronic cough, and shortness of breath. Th e aging individual's capacity to perform all kinds of functions gets progressively reduced. Eventually, the person goes under, like an old home giving in aft er a heavy downpour.'10 Th e psychological symptoms of aging have also been detailed by the medical practitioners of ancient India. Human beings have always wanted to overcome aging and to live as long as possible. But eternal life in the human body has eluded them. Ancient systems of medicine are believed to have contained keys to delay greying. Today we know that Ayurveda prescribes methods to delay the aging process. Longevity has also been explored in Ayurvedic texts. Ayurvedic practitioners would examine the newborn for signs of longevity. To delay the process of aging and overcome ailments born of old age, they prescribed rejuvenation therapy or rasayana and revitalization or vajikarana. Th ey are the ancient Indian equivalents of modern preventive geriatrics. Th e main principle behind these therapies is that a systematic synthesis of appropriate food, ahara, and balanced lifestyle, vihara, will lead to the rejuvenation of vigour, vaja or ojas, of the body. Certain natural substances were identifi ed as potential aids in rejuvenation which could considerably compensate for the wasting the body suff ers due to old age. In keeping with traditional Indian philosophy, Charaka says that moderation is the key to longevity. Th e body is compared to a vehicle: just as a ve hicle properly used wears out gradually but may break its axle if driven carelessly, similarly the body will last longer if used judiciously but will perish early if misused. Frittering away one's vital energies leads to physical decline, speeding up the aging process. A disciplined life with adherence to personal hygiene Ayurvedic physician, vaidya, examining a patient's pulse -No bleed here- PB April 2009276 was therefore considered important. Charaka defi nes old age as the period between sixty and one hundred years. It is interesting that the time of onset of old age as specifi ed by this ancient phys ician coincides with the age for retirement prescribed by the government of almost all countries. Rejuvenation therapy may produce remarkable results in recovering the vitality of an aging body and mind. It removes fatigue, mitigates weakness, improves digestion, enhances vigour, and improves skin lustre. Th e body is purifi ed by cleansing the intestines thoroughly and removing impurities from the circulation. In addition to physical purifi cation, these therapies also include chanting of Vedic hymns and the practice of silence, meditation, and contemplation. Th us, the process of rejuvenation is holistic, revitalizing both body and mind. Application of special medicinal oils and dietary hygiene are part of rejuvenation therapy. Even today this form of Ayurvedic therapy is very popular and attracts people from all over the globe to India. Present-day Health Care for the Aged Indian Shila's plight is a refl ection of the many problems faced by aged women in contemporary India, where specialized geriatric medical care remains a rarity. Even in hospitals with independent departments for care of the elderly, only the economically privileged few are able to aff ord these facilities. Traditional systems of medicine like Ayurveda are also very expensive, and the providers of these facilities are more interested in serving 'medical tourists' coming from abroad than catering to the needs of their fellow countrymen. In rural India the old are still taken care of within the family, but urban India is witnessing a displacement of older members to diff erent institutions, old-age homes in particular. Th e Indian medical system is yet to come to terms with the large number of households in the country which are not equipped to provide adequate nursing care for their elder members, with some of those families even unwilling to undertake such care. Government hospitals attend to the aged only if they are ill. Th ough Ayurveda considers old age itself a disease and though the physiological complexities of old age call for special medical care, an average senior citizen in India gets nothing but salutatory respect from Indian medical institutions. Even with a growing number of ngos coming forward to support the cause of the aged, it still remains to be seen whether society will respond to this problem by providing proper care to the elderly within the family set-up, or whether government and private enterprises will intervene and provide better institutional health care facilities for the elderly. Th e likes of Shila need to wait till then. The Social Dimension With a shift in traditional familial roles, the aged fi nd their activities curtailed, which in turn leads to a feeling of not being wanted by family and society. In the past joint family structures in India allowed the aged to remain an integral part of the family and act as guides to successive generations as well, handing over valuable family knowledge and social traditions. Th is gave them a useful engagement, and the parenting duties of their immediate off Medieval Ayurvedic physician at work -No bleed here- 277PB April 2009 Aging: The Indian Context 29 spring were also shared. In the process, childhood and old age-both phases of life requiring abundant personal attention-came in close contact. Even a few decades ago Indian society did not consider the aged a burden, but treated them as valued keepers of tradition deserving respect and care. The increase in nuclear families, a consequence of the rapidly changing cosmopolitan nature of jobs, moved the elderly from an adored position to one of a fringe group that had to be somehow tolerated. This paved the way for old-age homes. Children too are now kept very busy by the demands of curricular and non-curricular education imposed on them by a highly demanding society; they have no time to sit and learn from the generation that brought up their parents. With the 'de-traditionalization' of society old age is no more a hallowed institution. The culture of old-age homes is not prevalent in rural areas, but urban India is rapidly opting for the convenience of dumping its senior citizens in institutional care facilities. Though not considered proper in the Indian tradition, separation of ailing elders from one's home is today seen as an action, both pragmatic and essential, for coping with escalating social demands. Tumultuous changes in urban Indian lifestyle have only accentuated such perceptions. For instance, the daily routine, or the lack of it, of the average youth can only shock their grandparents. Instead of rethinking the nature of this cultural shift, society prefers to take the path of least resistance: avoiding or neglecting the previous generation. Overall health care in India has improved over the years and consequently the population of the aged is steadily increasing. But the country is illprepared to provide for the elderly segment of its population. There is no systematic welfare programme for the aged and they are largely left to themselves. The old are expected to only lead a religious life without much participation in social activities. Notwithstanding that this trend is due to the cultural inheritance from Vedic times, such an attitude does not always allow the aged to cultivate diverse interests to quell their boredom. Moreover, even when elderly people go on pilgrimage they find it difficult to access the amenities needed for alleviating their physical strain. The provisions made for taking care of the special facilities the aged require during travel are still rather rudimentary. In India aging and the elderly have generally been looked at from the male perspective. The problems specific to women-aggravated by the fact that they usually outlive their husbands, who are their principal financial support-have never been properly addressed from a feminine perspective. Old age for a typical Indian woman turns out to be a mere extension of her subordination to a patriarchal society. With bodies failing and household activities nearly absent, elderly couples feel the need for close emotional understanding extending beyond the physical plane. In a largely orthodox patriarchal set-up this often becomes difficult. Problems brought about by the dynamically evolving cultural ethos of Indian society are being addressed by specialized research institutes. Many universities have started courses focusing on the problems of aging and the aged with specific reference to the Indian situation. While it may take several years for these studies to find practical application, society as a whole needs to take steps to make sure that this issue does not get out of control, as it has occurred in countries like China where caring for the aged population has turned into a major crisis. Retirement plans for the old should not only be economically oriented but ought also to address the inevitable lifestyle changes required of the elderly. Though in the government of India there are separate departments for women and children, there is no specialized department for senior citizens; their needs are presently addressed by the department of social justice and empowerment. In 1999 the government formulated a 'National Policy for Older Persons'. Various schemes were undertaken in pursuance of this policy. These include: Strengthening of primary health care system to enable it to meet the health care needs of older -No bleed here- PB April 2009278 Prabuddha Bharata30 persons; training and orientation to medical and paramedical personnel in health care of the elderly; promotion of the concept of healthy aging; assistance to societies for production and distribution of material on geriatric care; provision of separate queues and reservation of beds for elderly patients in hospitals; extended coverage under the Antyodaya Scheme with emphasis on provision of food at subsidized rates for the benefit of older persons, especially the destitute and marginalized sections.11 Nevertheless, the concerned executive agencies need to ensure greater penetration of these policies at grass-roots level to be of real use to society. Financial Security The question of financial security in old age bothers everyone, even the youth. People save large sums of money, purchase real estate and gold, and invest in stocks and shares to ensure that they need not depend on others for their daily needs when old. In spite of all these precautions, it is seen that a minor fluctuation in their cash reserves entails lots of problems for the aged. The elderly often get adequate care and respect only if they have money to spend. Table I below gives an idea of the economic independence of the aged in India as reported by the 'nss Fifty-second Round: July 1995–June 1996', published by the National Sample Survey Organization, Department of Statistics, Ministry of Planning and Programme Implementation, Government of India, Calcutta, in 1998. This table brings out the striking disparity in the economic freedom enjoyed by the elderly male and female populace of India. About half of the aged male population seems to be financially independent, as against a meagre 11–12 per cent of females. The government of India offers many financial benefits to the aged, including income-tax rebates, old-age pension, additional bank interest, and railway and air fare concessions.12 Still the majority of the elderly do not see themselves as financially independent. Wealth can bring additional problems for the aged, rendering them more vulnerable to burglar attacks, constant demands from relatives, and litigation. The Indian government needs to develop Table I: State of Economic Independence of the Elderly in India (per cent of people aged above sixty)13 State of Economic Independence Male Female Rural Urban Rural Urban Not dependent on others 48.5 51.5 12.1 11.5 Partially dependent on others 18.0 16.9 14.6 11.0 Fully dependent on others 31.3 29.7 70.6 75.7 Not recorded 2.2 1.9 2.6 1.8 special mechanisms for handling litigations involving the aged. The recent killings of retired people for money in posh residential localities of the national and state capitals are matters of serious concern. Such incidents snatch away the mental peace of old people and bring home to us the helpless situation of the elderly in urban India. All the same, financial freedom is essential for proper sustenance, security, and health in old age. Everyone ought to be prepared for old age by saving sufficiently, if one is to avoid Shila's financial predicament. Embracing Old Age and Death At the dawn of our lives, with the effulgent rising sun of vitality and vigour bringing with it distant beauties and promises veiled by the mist of expectation and inviting us to uncover them, we are totally unprepared for old age and death. With a refreshing feeling in our minds and a 'can do everything' spirit, we plunge into activity amidst the happy chimes of life's small joys. About midway through our lives, with heavy responsibilities to shoulder and lots of dreams yet to be fulfilled, we console ourselves thinking that there is just a little more to be done before one can rest. We seek occasional retreats and come back to work with renewed vigour. -No bleed here-