• Published Date: 15 Jul 2019

    HDB's Reply

     

    HDB worked closely with Dakota residents for relocation
    Date: 1 May 2019

     

    We refer to the commentary (Who guards the bodyguard? The ethics of care for older adults, April 7). 

    The writer, Dr Ad Maulod, shares views on the ethics and ecosystem of care for older adults, with reference to the account of one resident who was relocated from a Housing Board rental flat in Dakota to one in Cassia Crescent. 

    We agree with the writer that "care should be person-centred and operate through a network of agencies and individuals caring interdependently with, rather than independently of, each other". 

    For the residents in Dakota, HDB worked closely with the Relocation Task Force initiated by Mountbatten MP Lim Biow Chuan and voluntary welfare organisation Tung Ling Community Services, which was familiar with the residents, having been sited in the Dakota flats area for many years. 

    Each household had an HDB contact officer they could approach, and there was an onsite inquiry station and dialogue sessions for residents to raise any concerns about the relocation process. 

    There were also site visits to the new flats in Cassia, all of which have universal design features like ramps and grab bars, making them more senior-friendly than the old flats in Dakota. All residents also received an allowance to help defray relocation expenses. 

    For the move itself, the Relocation Task Force helped needy residents move their belongings and provided complimentary furniture. Those in need also received financial support for the costs involved. 

    We understand the writer's point that care should extend beyond physical needs to encompass each individual's emotional and social needs, including that for dignity, autonomy and friendship. 

    HDB and various partners - government agencies or otherwise - put in tremendous effort to support the Dakota residents during the relocation. We recognise that even then, we were unable to support each individual fully, given the limits on our resources, such as manpower. 

    We are thus grateful for the support given to the residents by community leaders, and aim to work more closely with community partners for future relocations. 

    Foo-Ho Yoke Ming 
    Director (Rental Housing)
    Housing and Development Board

     

     

    Commentary in The Straits Times

     

    Who guards the bodyguard? The ethics of care for older adults
    Date: 7 Apr 2019

    From: Ad Maulod

     

    In this essay, a cultural anthropologist looks at the help given to Tong, a resident at Dakota who is being resettled, and reflects on what the case says about the way help is given to the elderly and the poor in Singapore. 

    Tong honours the legacy of the late Mr and Mrs Lee Kuan Yew by placing their photographs at the entrance to his old Dakota flat. Will the photographs survive the move to his new, but much smaller, residence? 

    Once a bodyguard to Mr Lee Kuan Yew, 90-year-old Tong's contributions to nation-building have not gone unnoticed. Together with more than 450,000 of his contemporaries born before 1950, he forms the Pioneer Generation currently entitled to additional healthcare subsidies. 

    Tong, however, is struggling. His health is deteriorating, his mobility is limited. He has to borrow money just to buy food, which eats at his self-worth and dignity. Tong rationalises that pride cannot feed you. Yet he wonders if life is worth living when one has to "borrow and return, borrow and return," to get by. Tong talks about taking his life and, at one point in his interview, his hands gesticulate as if falling from a great height. 

    Tong's recollection of his life does not always articulate failure and shame. There are successes: after serving Singapore's first prime minister, he went on to do well in construction. There is also misfortune: when he got caught up in gambling. Then again, Tong never had actual wealth to lose. He has always lived in rental housing, too busy working to take stock of the neighbourhood. Unlike his contemporaries, he has no rich memories of the estate. He decided against marriage, because "women were all about the money". Issues of money - and the lack of it - have shaped his entire worldview about what it means to live a good life. Money defines his access to social participation and ability to raise a family. It explains his isolation and lack of self-worth. 

    Moving from Tong's story to the way we talk about care in Singapore, I had several reflections. Why should we care about Tong's story? How should we care? Who owes Tong a duty of care? 

    THE ECONOMY OF GRATITUDE, THE OPPRESSION OF GOODWILL 

    Care must go beyond an economy of gratitude. Rocky's critique (an earlier essay in the book by the volunteer who befriended Tong) of the Pioneer Generation narrative is both nuanced and poignant. Linking access to basic needs such as food, health and shelter to a "contribution-based calculus" amplifies prevailing norms and attitudes around deservedness and entitlement. This economy of gratitude may also propagate the notion that when support is provided, recipients should be grateful and should not question the status quo, even when the care that is received does not match actual needs. 

    An economy of gratitude can generate an oppression of goodwill.  

    Channelling resources into things and programmes which do not address current unmet needs is not only wasteful, but also oppressive. 

    When I first started my research in a public rental estate in Chinatown, I was happy to see food rations in the homes of the older residents I interviewed. At least they were cared for and had some provisions to tide them over. 

    However, this warm feeling turned to annoyance only a few months later. A single bag of rations by the doorway had multiplied into three or four. Bags of rice were infested with weevils. Tin cans were bloated. Boxes of crackers and bottles of oil remained unopened and were left to expire. The older adults I met said they did not need these things because most of them lived alone and it was more economical to eat at the hawker centre than to cook for one. A diabetic person said they were unsure if they should be drinking Milo or eating biscuits. 

    They had not asked for these provisions and were uncertain how to return them or dispose of. More importantly, the residents hesitated to reject these items lest they be judged as arrogant or, worse, no longer "needy". Finding space in their homes for these things was a minor inconvenience compared to the risks of losing assistance. 

    When I visited the new Cassia Crescent estate, the Cassia Resettlement Team (CRT) volunteers showed us a reflexology footpath in the void deck. Reflexology footpaths are a favourite among older adults. 

    But at Cassia Crescent, the only reflexology footpath is tucked behind a maze of pillars, on a ledge that is about 60 centimetres high, with no rail support at all. In fact, it was not clear whether the pebbled ledge was meant to serve the function of foot reflexology or was merely decorative. Without regard for the safety of older residents who may be frail or need mobility assistance, and no clear understanding of how facilities are utilised, a public good becomes a waste. 

    The Japanese have a concept called mottainai which means "what a waste!" 

    In the otagaisama community model, based on the principles of inclusiveness and mutual help, researchers, local residents, community activists, corporations, and non-governmental and not-for-profit organisations collaborate to assess and fully utilise their resources to create a comfortable, age-friendly environment for all. The concept is simple. Ask people what they want, then turn what is currently unutilised or underutilised - that is, "waste" - into something useful for everyone. 

    In aspiring to be a city for all ages, Singapore can benefit greatly from an ethical framework like mottainai, where the fundamental principle is for citizens to participate in decision-making processes that will create understanding of actual community needs. Goodwill should not be oppressive, but democratic and participatory. It should redistribute and maximise benefits to all. 

    AGEING-IN-PLACE WITH DIGNITY 

    The efficacy of health and social services in Singapore tends to be measured in terms of tangible returns. In the provision of integrated care for frail and poor older adults, this translates to expecting improvements in functional capacities - physical, cognitive, and psychosocial - even though physiological and cognitive decline are inevitable in the ageing process. Also known as a "trampoline" model of care, this approach assumes that everyone has the resources, as well as the physical and cognitive capacities, to "bounce back" from adversity. The natural and biological process of becoming frail as we get older is stigmatised as failure on the part of individuals or burden to someone else.  

    The "trampoline" model also assumes that individuals only switch between two conditional, oppositional states: normal/sick, healthy/frail, independent/dependent, active/inactive. These dichotomies are more ideological than practical, as people's actual conditions are on a continuum rather than absolutes. 

    Judging needs using a binary mode of thinking ignores the agency of older adults in measuring "successful" ageing on their own terms. 

    The Singapore state requires that citizens do not age themselves out of productivity, particularly employment. In the Action Plan for Successful Ageing 1 - a blueprint for Singapore to become a place where citizens can "age successfully" - financial independence through "lifelong employability" occupies a prominent place. For those who cannot work, there is a different reality. As Tong pointed out: 

    "Singapore is a good place for middle-aged people, not for elderly people. Lee Kuan Yew built this place so that middle-aged adults can lead a good life… because they have a lot of CPF savings." 

    Public messages continue to showcase the ideal senior citizen as self-reliant and an active contributor through continued employment, volunteering, or family caregiving, with distinct neoliberal overtones of personal responsibility through productivity instead of reliance on public welfare. For frail and poor older adults like Tong, a "good life" is materially impossible - the $500 of "charity money" he receives each month barely covers his daily needs. Yet they blame themselves for their current struggles. 

    Tong's anxieties about being burdensome and his strong sense of helplessness are exacerbated by the relocation to Cassia Crescent. He is aware that the flats at Dakota are old and the foundation has gone weak "like tofu". But he also describes how frightening it is to move to an unfamiliar place, even after inspecting his new flat many times. 

    He worries about the upfront costs of moving, the possible penalties to pay if he fails to restore the old flat to its original condition, and trip hazards in the new flat. His anxiety is palpable throughout the interview. 

    The relocation of older residents from Dakota to Cassia needs to be juxtaposed with current ageing-in-place programmes in Singapore. In the last decade ageing-in-place has become a buzzword when talking about population ageing. It refers to an enabling ecosystem where people can live in the residence and community of their choice, safely, independently, and comfortably. These ethical principles were startlingly absent in the relocation process. Tong's experiences bring to light the traumatic effect of relocation on older people's health and how it heightens social isolation. 

    The CRT was formed precisely because of a lack of befriending care to help the residents to adjust to their new environment. But it should not solely be on volunteers to facilitate such a transition through unrecognised emotional labour. Questions must also be asked of other public and professional service providers who are responsible for the residents. 

    Citizen participation and welfare should not be compromised for development's sake. Perhaps relocation is inevitable for the residents' safety. But more could have been done by government agencies to ensure the residents were able to voice their concerns and, more importantly, to follow up on these concerns. 

    From Tong's interview, these range from providing up-front moving costs and fall prevention programmes to re-orientating the residents to their new flats. Development processes need to be democratic, such as asking residents what makes Dakota feel like home and replicating the elements in the new estate. 

    Despite a nationwide focus on age-in-place care, age-friendly neighbourhoods, and isolation and suicide in old age, Tong is right: there seems to be no place for some elderly people in our country's future, and no dignity for them in ageing. 

    EMPATHY CAN BE A POLITICAL ACT 

    The idea that other people matter to us is the foundation of a moral and just society. Yet this seems to contradict the anti-welfare stance that individuals and families should care for their own, while turning a blind eye to larger systems and structures that continue to perpetuate inequalities. In this climate of "responsibilised" citizenship, empathy is a political act. How do we make other lives matter? 

    The friendship model of care poses a counterpoint to current approaches to eldercare, which tend to pivot on a "misery perspective" that focuses almost exclusively on the recipient's vulnerability to the benevolent carer or the caregiving burdens placed on the care provider, rather than reciprocity between them. The older person is seen as frail, ill, lonely and passive. 

    Their personal agency is subsumed under the status of care recipient - objects of sympathy rather than persons who contribute to the caring aspirations of others. 

    In contrast, Rocky's friendship with Tong expands the focus of caring relationships beyond vulnerability and burden. Their friendship is an intimate intervention that promotes Tong's autonomy, integrity and dignity by understanding him and his needs through meaningful interactions. Friendship that is grounded in empathy, that reserves judgment and values people's life experiences, potentially extends care beyond the transactional provider-recipient dynamic. 

    The language of friendship makes care more dignified, especially for those who worry about being a burden. It is a practice that cultivates compassion. For Tong, his friendship with Rocky may encourage self-compassion because the help that comes through the CRT is not associated with degradation and shame. 

    For care providers, it confronts them with difficult questions about autonomy and dependency. In the beginning, Rocky focused on Tong's desire to regain mobility and resume cycling, which he used to enjoy. As their relationship developed, Rocky realised that Tong had other needs for companionship and financial security, which were equally important to his self-determination but had not been treated with the same priority and urgency. Their friendship allowed Rocky to recognise his own privilege as a volunteer to determine needs, care gaps and priorities. A transformative friendship is one that redresses the balance of power towards reciprocity and mutuality. 

    The friendship model of care may open up a Pandora's box of unmet needs. The possibilities of empathetic engagement depend on access and limited resources like time and labour. Rocky and Tong share a friendship that arose from, and is bounded by, Tong's needs: visits to Tong's home gradually tapered off once Rocky and the team felt that he had regained his strength. In this regard, relationships of care reveal complex links between empathy, actual needs and power. They raise important questions: Whom does empathy benefit? What does empathy serve? Who decides when empathy applies? Who remains apathetic? Who continues to perform unrecognised emotional labour? How can we make care "world-repairing" by addressing unequal hierarchies of power that determine who is excluded from care and who is excused from caring? 

    Despite the radical promise of respect and choice, it is inadequate to depend on friendship alone for care. 

    A friendship model of care has to be embedded within a larger ecosystem based on human rights that protect older adults' dignity and autonomy. 

    Our first steps should be to ensure that institutional mechanisms are in place to enable older adults to participate in decision-making on matters that directly affect their well-being. There should also be a system of accountability and monitoring of standards to ensure that needs are addressed through the design and delivery of health and social services. Care should be person-centred and operate through a network of agencies and individuals caring interdependently with, rather than independently of, each other. 

    So who is responsible for caring for our vulnerable citizens? We who breathe the same air and pass each other in the same space - we all are. 

    We owe Tong a duty of care because acts of compassion are an investment in social norms - it is perfectly normal, reasonable, and dignified to ask for, receive, and give help simply because there is a need. 

    Rocky expresses it aptly when he says that dependent relationships are a normal part of human affairs and vulnerabilities are part of our lives. We want to thrive and grow old in a compassionate society, inheriting the system of justice that we build. Who doesn't want to live in a decent society? 

    Ad Maulod, a Research Fellow at the Centre for Ageing Research & Education (Duke-NUS Medical School) is a cultural anthropologist whose research engages intersectional approaches to explore ageing experiences and health/social disparities in later life.