“WHO GUARDS THE BODYGUARD?” The ethics of care for vulnerable older adults, an essay by cultural anthropologist Ad Maulod

Ad MAULOD is a cultural anthropologist whose prior research looks at reproductive rights and same-sex family practices in Singapore. This is an excerpt of Ad's essay from They Told Us To Move: Dakota—Cassia edited by Ng Kok Hoe and the Cassia Resettlement Team, which looks at public housing resettlement in Singapore through the eyes of Dakota residents, volunteers and academics. This piece builds upon the experiences of former resident Tong, which you can read more about here, and a reflection by Cassia Resettlement Team volunteer Rocky Howe.

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 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.

 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. 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 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 this 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.

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 S$500 of “charity money” he receives each month barely covers his daily needs.

Tong’s anxieties about being burdensome and 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 judgement 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 opens 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?

Notes

  1. Ministry of Health. (2016). Action plan for successful ageing. Retrieved from:

https://www.moh.gov.sg/docs/librariesprovider3/action-plan/action-plan.pdf

Ad MAULOD is a cultural anthropologist whose prior research looks at reproductive rights and same-sex family practices in Singapore. Ad is currently a Research Fellow at the Centre for Ageing Research & Education (Duke-NUS Medical School) whose research engages intersectional approaches to explore ageing experiences and health/social disparities in later life. Ad is an advocate for inclusivity and diversity across the life-course. Current research projects are about elder poverty; lifelong learning and the learning divide; age-segregation and intergenerational relationships; integrated care and health empowerment; and finally, building relationships with older adults as research partners.

 About They Told Us To Move: Dakota—Cassia

They Told Us to Move: Dakota—Cassia tells the story of relocation through a three-part conversation, involving interviews with the residents, reflections by the volunteers of CRT who have helped them with resettlement, and essays from academics. Together, they draw out the complex issues underpinning each story, including urban planning; gender and family; community development and participation; ageing, poverty, and social services; civil society and citizenship; and architectural heritage and place-making.

The book explores human stories of devotion, expectation, and remembrance. It asks what we can achieve through voluntary action and how we can balance self-reliance and public services. This book is for people who want to understand the kind of society we are, and question what kind of society we want to be.

They Told Us to Move: Dakota—Cassia is available at all outlets of Books Kinokuniya, Times Bookstore, Grassroots Book Room, and here on our website 

 

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