North Ogden, UT
Taking Care of the Elderly in Peru
During my second week in Peru a group of friends and I were walking near the city of TrujilloŐs main square, the Plaza de Armas, on our way to get cake as an elderly woman was weaving her way through the crowds, all four and half feet of her. She had a small frame by nature, but she was badly hunched over making her look shorter than nature intended. She was wearing a black trash bag around her neck, in the fashion of a cape, and her feet were callused and black with thick soles. She was saying something in Spanish that I did not understand and was walking with her right hand cupped and held out in front of her. Her hair was salt and pepper colored, long, and ratted. I never looked directly at her face, but I could feel her looking at mine and I began to panic. Instead of being the first person at field school to break down in tears, I fought them back and changed my mind towards something else until I was alone and could think about what I had just witnessed. Later that night I found myself asking who that woman was and why she was wandering the streets. I assumed that she was begging for money and that she had no one to take care of her. WasnŐt there some place for her to go? Why were people walking past her and not helping her?
This scene caused me to develop the research question that would guide the work I would do in Peru over the next five weeks; who takes care of the elderly in Peru and why? Every culture thinks about aging differently, but words like retirement, nursing homes, home healthcare, and rehabilitation donŐt usually cross the minds of most Americans in their twenties. It seems so far in the future that itŐs not worth sweating over in the present. Yet, time catches up with us faster than we think it will. Americans are finding themselves at the age of retirement without any money to live on. Many people are not prepared for when a sudden illness strikes, and the effects can be costly. Social security can be a headache to work with and any outside help does not come at a cheap price. The American way of life is fast paced and selfish; taking time out to help others is often impossible and there is just enough time in our day to get by. It is not uncommon to hear us ask, "Where did the time go?" We find ourselves spending more time at work than at home. Thus, it is not uncommon to try and find a way to relieve our burdens that are time consuming, such as taking care of an aging parent. As our parents grow older they may need more supervision and help with activities of daily living (ADLŐs). If one parent dies we may find ourselves taking care of a widowed parent who may be unable to live alone.
I work as a Certified Nurses Assistant (CNA) in Utah and spend much of my time witnessing the effects of what happens when elderly people do not plan for their future. It can be devastating to the individual and can tear a family apart. Nursing homes provide the answers for many of the problems that taking care of an aging parent presents. In a nursing home there is constant supervision and adequate care 24 hours a day, allowing people to continue living their busy lives without skipping a beat. This is the case where I am employed. When we get new residents at my work, their children will often say to me, "I donŐt want my parent to be here, but I just donŐt have the time to watch them and they cannot be left alone." When I arrived in Peru I hoped that attitudes towards care of the aging would be different, and they were.
Peru is home to 25 million people and has extremely diverse terrain. My research was done in the towns of Huanchaco and Trujillo, both on the northern coast of Peru with Huanchaco being eight miles north of Trujillo. Huanchaco is home to roughly 50,000 people with Trujillo being home to 615,000. Tradition in the town and within the family is still popular in the fishing town of Huanchaco, a place famous for its fishing boats made from reeds called caballitos de totora. Due to archaeological findings, good surfing, a good reputation, and the quietness of the city, Huanchaco has seen a rise in population and tourism. This amazing little town and its people were my home base for the five weeks that I did research on care of the elderly.
In my three years of work as a CNA in the U.S. I have seen all different types of situations that are involved in paying for nursing care and making sure that the quality of care is adequate. Upon arriving in Peru I thought that it would be interesting to study the quality of care given in nursing homes in the U.S. compared to the nursing homes in Peru, but that idea quickly died. Within the first week of my arriving in Peru I learned that there was only one nursing home within my immediate reach, which included the third largest city in Peru, so I decided it would be impossible to do a cross cultural comparison between care in Peru and the U.S. Instead of focusing strictly upon nursing homes, I thought I could do more by examining non-institutional care combined with institutional care including how which is decided upon and by whom.
Toward the beginning of my research I witnessed another incident which deeply impacted my research. A local festival was taking place and I was able to watch it from the balcony of my hostal. As the festival was ending, people in the town square began to go their separate ways, but an elderly man in a suit and the middle aged woman on his arm caught my eye. I described what I saw in my field notes from that day:
He is wearing a gray suit with a white and gray tie and black shinny dress shoes. She is wearing a mustard colored sweater, black dress pants and tan shoes. They are both dressed nicer than those around them. The old man is holding onto the womanŐs arm with his left hand. In his right hand is a cane made of silver metal. He is moving extremely slowly and the woman shows no signs of impatience with him.
I watched as she walked him to edge of plaza and together they watched the precession. All the while she held his arm and when the precession was over they walked away together, the woman guiding the old man.This completely restored my confidence in the local social structure and I was confident that I could emotionally handle the topic because I had now seen the good side as well as the bad.
I collected the information used for this paper in several different ways. I speak no Spanish so it was difficult to do formal interviews with people, and my contact list of who I could speak to was definitely limited by this. To get around the language barrier I spent close to eight hours over two weeks volunteering at Hermanitas de los Anacianos Despamparados (Sisters of the Elderly without Protection), a nursing home in Trujillo run by an order of nuns called the Patron of the Ancient. This allowed me to do participant observation within the walls of the building. I did hands-on work side by side with the staff at the nursing home, allowing me to observe daily life for the residents as well as being able to observe what kind of care the residents were receiving in comparison to nursing homes in the U.S. Nursing homes are not a part of normal social care of the elderly in Peru, so this gave me a chance to see how good "last resort" care is for the elderly in the area. I was also able to ask one of the nuns who works in the front office, Madre Rosa, a few questions about the nursing home and the work they do.
Second, I did ethnographic interviews with two people. Again, I am not fluent in Spanish, but I was fortunate enough to find two people who spoke English to do interviews with. First, I talked with a 32-year-old Peruvian man, that I will call Abel, who currently lives with his elderly mother and two of his brothers. Abel and his brothers all work together to take care of their mother. Second, I talked with a local Huanchaquero, who I will call Cesar. Cesar spent six months with his brothers taking care of his father as he died of cancer and now they take care of their 76-year-old mother. CesarŐs father died in February of cancer and had been sick for six months. All of his brothers have taken part in caring for their aging parents, but because his two sisters live in Lima (an eight our trip to Huanchaco by bus) they have unable to contribute much time. This allowed me to gain insight into how the social customs arrange the care of the elderly who do, and do not, have retirement money set aside and what the younger Peruvians are doing to ensure that they will be well taken care of while they are aging.
PeruŐs life expectancy for women is 71.03 years and 67.48 for men, making only 5.1% of PeruŐs population over the age of 65 (Central Intelligence Agency). Retirement usually occurs around age 60, but more formally it takes place after 30 years of steady work. With only seven years between retirement and oneŐs life expectancy it easy to understand why someone would be reluctant to set money aside during their working years if they donŐt expect to be alive for a long period of time. One top of that, thereŐs no reason to set money aside on top of relying on social security because you know that your children will take care of you within that time period. Time coupled with social customs can explain who takes care of the elderly in Peru and why.
Role of the family
Due to stereotypes I had a feeling that family in South America was considered top priority before arriving in Peru, and my research further enforced those beliefs. Both Abel and Cesar stated that the family comes first and it is everyoneŐs job to look after their family. Who takes care of the elderly depends on the family structure, but most often the responsibility falls on the shoulders of the youngest child or usually the women.
My interview with Abel was my first ethnographic interview and he was extremely helpful in opening up my eyes towards how the system of family provided healthcare works in Peru. "In Peru the family is very important," Abel told me within the first minute of our interview, "In Peru you will be poor if you do not have any family." When I asked Abel to explain to me how the family provides care for an aging parent he quickly told me that children do in fact take care of their parents, but which of the children do it and how they do it depends mostly on the family itself and also on whether or not the parents have any social security funds to draw from.
While Peru does have large cities with people working legal jobs (meaning that they are not being paid under the table and the government is withdrawing some taxes from their income), it also has many people who are working in the secondary economy or may not be working at all. The majority of these people live in the mountains or on the outskirts of major cities, making it more difficult to find employment. These people do not have any social security to draw from and must rely on their children to care for them when they are older. Many families who own a home will simply build a new floor on top of their home to accommodate for a parent who is moving in or visa versa. When I asked Abel about people who do not have social security to draw from he told me "Family is their social security." Without family these people would end up on the streets of large cities begging to survive.
Cesar explained that taking care of someone is more than just a duty; he describes it a sense of commitment that one must follow through with until the duty is done. When talking about his father, he said, "He was here with us until the end. TheyŐll take care of them until the end, most families." It is not unusual for a child who lives a long distance away from their parents to stop their lives for several months or years and move close to home to watch after them. CesarŐs explanation complemented what Abel told me earlier, that the decision of who will take care of the child also depends on the family structure, but there seems to be some regularities as to who will do it. He had this to say:
Usually the one that is more free, has more time, or the one that cares more about it. Usually, it will be more the younger one. The younger one will do it more. ButÉ itŐs not the rule. ItŐs mostlyÉ the women.
The woman is seen as the caregiver so naturally the responsibility falls on her shoulders. She also the member of the family who is more likely to be unemployed, making it easier for her to drop what she is doing in life and take on more responsibility. Younger children will find themselves taking care of a parent more often because they are still living at home when the parentŐs health begins to fail, while older children may have started families of their own making it difficult to take on new responsibilities.
Issues of money
In a country where 54% of its residents are below poverty level, one would imagine that the costs to take care of one or two parents would be an added stressor (Central Intelligence Agency). The costs of taking in a parent can add up with food, medicines, clothing and housing expenses. Having social security to help pay for everyday costs can lessen stress, but many Peruvians do not have that cushion to fall back on.
AbelŐs story is common for middle class families within Peru. His mother worked at what Abel calls a "legal" job when she was younger and through her pay social security was taken out, allowing her to draw funds from it later in life. The house that his family lives in had already been bought and paid for when his parents were younger, eliminating any housing costs that might come with taking care of his mother. The only heavy cost that the family must deal with in taking care of their mother is purchasing food. According to Abel, he and his two brothers all work together in providing any funds for their mother that social security may not cover. When I asked Abel if his mother was happy living with her sons he told me, "She feels good with them."
In the case of many middle class Peruvians, it is not a financial burden to look after parents due to social security. In the case of CesarŐs mother, she is able to draw from her deceased husbandŐs social security to live off of. This type of social security will also cover unmarried daughters of the father as well as the mother. His father worked a steady, well-paying job for 35 years and CesarŐs mother gets half of what his fatherŐs last salary at his job was paid on a monthly basis. Without the insurance to help cover costs of the six months of illness that CesarŐs father had, the family would have ended up paying $15,000 dollars; instead they only had to cover $3,000 dollars. Families may also be reluctant to place a dying relative in the hospital due to the hygienic state of the hospital itself. Even though insurance will cover much of the cost, insurance also dictates what hospitals an individual can receive care at under the insurance plan and often times they are not well equipped hospitals. Instead of placing their family in a hospital that they see unfit for their loved ones, people can try to bring as much of the hospital into their home that they can. For example, in the last month of CesarŐs fatherŐs life, he had two nurses that each worked 12-hour shifts. This arrangement insured that someone was with his father 24 hours a day, a service that insurance will not cover. Cesar was clearly interested in taking his father to the hospital, but said this in our interview:
We could have taken him, though, to the hospital and that would be part of the insurance, but that would be very ugly for us. Because he didnŐt really need to be in the hospital and that would be part of the insurance, but that would be very ugly for us. Because the hospitals are not so nice here. Especially the hospitals that the insurance pays. I mean, they are not so nice. So you donŐt want to have your father in one of these ugly hospitals, right? I mean, itŐs not like a really nice, cleanÉ ItŐs not like that.
With such an importance placed on family taking care of family, it was hard to imagine how any Peruvian could place their parent in a nursing home. I wondered if maybe AbelŐs mother would feel better being taken care of outside of the home. He responded, "[In Peru] the custom is to take care of your family." He went on to tell me that only a "cold" person would place their mother in a nursing home. Abel explained that not only would the parent feel abandoned, but society would look down on a person who would do such a thing. By placing a family member in a nursing home, it is sending the signal that they are not important to the family and they can be easily disposed of.
When I asked Cesar why he chose not to put his father in a nursing home his reasons were social and financial. "No, itŐs not socially acceptable. I mean, you be umÉ you be in the group of mean children." Even if society sees it as a poor decision, the choice also has to weigh on the conscience of the individual because the state of nursing homes in Peru are not as clean and caring as the home itself. Although, if PeruŐs nursing homes were in a cleaner state it seems like some individuals might reconsider taking care of their parents full time and allow their mother or father to live in a long term care facility. Cesar had this to say about nursing homes:
Of course one reason also not to take them there is because itŐs not a really nice place. [If it was] really nice with, like, big huge gardensÉ I donŐt know. Like something that I saw on TV, maybe we would take them there. Maybe theyŐll be happier there. Because they know how to take care of them and of course that probably will cost a lot and maybe you will have to pay a lot, but the situation with Peru, that isnŐt allowed, that kind of service.
To discover what really happens to those who do not have family to rely on, I went to Hermanitas de los Anacianos Despamparados. This was the most difficult part of my entire project. I was curious to see the state of nursing homes for my own sake, but after learning how Peruvians feel towards care outside the home I was determined to discover why there was such a negative feeling associated with it. Hermanitas de los Anacianos Despamparados is the only one in Trujillo and takes care of over 130 residents, 56 women and 73 men, ranging in age from 60 years to roughly 108. Unlike in the U.S., where family members bring their parents to the nursing home to live, many of these elderly people are found wondering the streets or are brought in by police or charity workers.
My first impression of the building was that it was a great facility behind the walls that protected it from a sketchy city. I was so impressed that I wrote this in my field notes from the first day that we visited:
There is a beautiful garden in the front that is on either side of a path that leads from the front gate to the front door. A man let us in at the front gate and a nun met us at the front door. Inside the walls were green and it was one of the cleaner buildings I had seen so far in Peru. There were beautiful pictures of saints and monks on the walls around the waiting area.
Being so impressed by the scene when I first entered made it easy to be excited about doing some volunteer work there. The first day that I arrived I was very excited and ready to do some hands-on work that I thought would be similar to my job at home.
On my first day of work there I was lead through a part of the building that contained a lovely outdoor courtyard with residents seated around the courtyard. I was taken to a room at the back of the courtyard that contained ten women, most of whom were in wheelchairs, and one nun who was clipping her fingernails. When I first saw the elderly women I rushed a little quickly to get in the room, being excited to get started, but I was quickly slowed down by the overwhelming smell of urine.
Over the next two weeks I saw much care and attention showered upon to residents by the staff of nursing home. Attention was given to details like making sure that nails were trimmed to feeding residents who were blind and unable to feed themselves to comforting a crying resident. The care given, in terms of affection and tenderness, paralleled those found at my job in the States. But at the same time I was able to understand where Abel and Cesar were coming from when they said that nursing homes were not the greatest place for their parents. The place seemed to be understaffed for the amount of residents that they were taking care of, so many small things did go unnoticed. For example, residents were walking on slippery tile without good shoes on and some were wearing clothing that needed to be changed, but the staff may not have the time to see that it is always done. Much of their clothing did not match or seem to fit properly, but they were all dressed according to the weather and many were covered with blankets if it was a colder day or they were not ambulatory. It easy to pick out the bad in something, but in the case of this nursing home love is abundant and their residents are taken care of to the best of the staffŐs ability. They are doing a great job.
It can be comforting to know that a great importance placed on family results in the elderly population being taken care of. While doing my research I saw many examples of love and support for the aging. Yet, it is important to note that my experience may have just been a good one. There are many elderly people in Peru who are not being looked after and are living a life of poverty and illness without any help. It is important to study this demographic because they are often over looked and yet, are the most in need.
If time had allowed, I would have liked to study what assistance, if any, the government is willing to give elderly people who do not have any social security to draw from. I would also be interested in studying how people who do not have families to look after them end up living on the streets and if the government is making any attempt to take care of those people. Any sort of assistance the government could offer to those who do not know how to prepare for the future could be immeasurable and life saving.
I would also like to thank everyone who helped me do my research and complete my paper. Thank you Bonnie and Chad for setting up my interviews, making sure I got to and from the nursing home safely, and answering all my questions patiently. My roommates and classmates have shown me an amazing time in Peru and I will be forever grateful. Thank you to the people of Peru, but especially the residents of Huanchaco, the two gentlemen that allowed me to interview them, and the staff and residents of Hermanitas de los Anacianos Despamparados. Finally, thank you mom and dad for worrying about me, paying my tuition, and making this opportunity possible.
Central Intelligence Agency 2004 The World Fact Book: Peru. Electronic document, http://www.odci.gov/cia/publications/factbook/geos/pe.html, accessed July 6, 2004.
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