BRUNON SYNAK

FORMAL CARE FOR ELDERLY PEOPLE IN POLAND

ABSTRACT. This paper starts by giving some brief information about the institutional care system for the elderly in Poland. The supportive network for old people is identified as being firmly based on that of the family. Social services are particularly directed to those without children and close relatives. There are many economic and socio-cultural reasons for raising the importance of institutional help - e.g. the growth of female professional activity, migration processes, the disintegration of the multi-generational family. The family contacts with old persons staying in hospitals and in nursing homes are described and the attitudes of the elderly towards institutional care are discussed in this paper. Presently old people expect t-maneial help mainly from the state but care and help in everyday contingencies from their family (e.g. in ease of illness, only 2% of old people would like to be cared for by nurses). This paper also shows some reasons for differentiating the attitudes and generational expectations. The family responsibility for elderly people reflects on the one hand the attitudes and systems of values of both the generations and shortage of institutional services on the other. Examples relating to some of the issues discussed are given in this paper. Key Words: Poland, welfare state, health, family, economic stress, Catholicism

FORMAL CARE FOR ELDERLY PEOPLE IN POLAND The need for formal assistance to elderly people in organising their everyday lives and in satisfying their basic needs is largely the product of demographic and socio-cultural premises. Two factors have led to the intensification of the need for external assistance to the elderly and infirm. The first of these is the growing percentage of the elderly in the total population due to lower birth rates and the prolongation of the h u m a n life span. The second of these factors involves changes in the structure and functions o f the family coupled with more general civil and technological transformations of society, as well as changes in accepted norms, values and cultural patterns. In Poland, family members, preoccupied with their working careers, have more limited opportunities for extending necessary care to their parents and grandparents. In consequence, we are witnessing growing social consent for replacing some family tasks b y institutional care. The extent o f formal care and its organisational structure is furthermore determined by political and economic factors. The analysis in this paper deals with a country organised along socialist lines and troubled b y severe economic problems. Moreover, tradition and the R o m a n Catholic Church continue to play a very important role in this country and the family continues to function as the most important self-help group. Thus, this paper has mainly focused on the interaction between cultural expectations and attitudes, economic circumstances and, to some extent, historical background. It is assumed that, in Poland, there is Journal of Cross-Cultural Gerontology 4: 107-127, 1989. © 1989 Kluwer Academic Publishers. Printed in the Netherlands.

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SYNAK

an incompatibility between cultural values and formal service provision. The attitudes of elderly people towards different forms of social care are differentiated and strongly determined by culture. The form of help, its effectiveness and attitudes towards it are considered against the background of the overall ageing of the Polish population and the health situation of the elderly generation, as the important conditions determining the prerequisites of this help. Domiciliary and institutional care services are discussed and examples given. In this description the socio-cultural context of care provision has been emphasised. 1. THE AGEING OF THE POPULATION IN POLAND AND THE HEALTH CONDITION OF THE ELDERLY Poland, like other East European countries, is still endowed with a rather young population structure. However, population ageing is proceeding at a similar rate to that of many other industrialized countries. During the present century the proportion of people 65 and older increased from 3.6% in 1900 to 9.5% in 1986. Over the post-war period, the number of elderly people tripled and the overall percentage is almost twice as high in 1988 than forty years previously. Nevertheless, during the last few years, for the fkrst time in our recent history, the proportion of old people has decreased. This is because the oldest cohorts currently consist of people born during the First World War and earlier which were decimated during the Second World War. The number of people aged 60-64 consists of those bom between the wars, a period of demographic explosion. In the immediate future this demographic peak will shift to the older age groups and there will be a higher percentage of old people. The average life expectancy of the population may be used as a supplementary prediction of the process of ageing, as well as an indicator of the health condition of the population. During the post-war period, life expectancy in Poland increased for all ages. Nevertheless, two important trends should be noticed in analysing average life expectancy in Poland during the last few years (Figure 1). In Poland, there is a relatively large difference in life expectancy between men and women. While in most European countries women live about 3-5 years longer than men, in Poland the difference is over 8 years. The other trend is evern more pessimistic. In the last years, for the first time, life expectancy has decreased both for men and women. According to my personal speculations, the main reasons for this are: heavily increasing environmental pollution and the deterioration of the quality of nutrition and standards of hygiene and medical care. It may also have resulted from the war experiences of the present old generation, 1 difficulties of everyday life and the greater psychological stresses which have appeared during the 1980s' economic crisis and the political disturbances. The most general objective predictor of the health of old persons is the mortality rate. In recent years there has been in Poland a slight increase in the mortality rate of all cohorts above 35, with the exception of the age category

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Fig. 1. Changes in average life expectancy in Poland.

80--

70.5 70

-

60

-

50

-

40

-

64.2~

73.8

75.4

74.5

66.8

66.9

66.5

I'-'-"

Females at birth M a l e s at birth

64.8 58.6

3O

2O 10 0

--

17.3

18.6

19.3

20.3

1 9 . 5 Females age 60

._ 14.7

15.8

15.5

15.7

15.1

I 1960

I 1970

I 1980

I 1985

M a l e s age 60

I 1952 .

.

.

.

.

.

1953

.

.

.

.

.

1961

.

.

.

.

.

.

1971

.

.

.

.

.

.

.

.

1981

Source: Rocznik Statystyczny (1987)

65-79 (Synak 1987). This tendency is especially distressing when compared with other countries. In Poland, in 1978 the death-rate in the case of men aged 55-64 was 20.9 whereas it was 13.4 in Greece, 15.9 in Holland and 19.8 in East Germany (Frackiewicz 1985). It is obvious that this situation may also be explained by the factors mentioned above, in the context of the fall in life expectancy. Functional ability of the elderly not only reflects the actual state of health but it is also a good indicator of the need for care. Table I summarises data from three studies made in different periods by Piotrowski and the Central Bureau of the Census in Warswa (GUS). It is apparent that in spite of the fairly long time distance between the studies of 1967 and 1980, they do not indicate any significant improvement in the functional ability of old people in Poland. TABLE I Functional ability of elderly people (%) Categories of ability"

Piotrowski (65+) (1967)

GUS (65+) (1980)

GUS (60+) (1985)

A B C D

63 27 6 4

64 27 7 2

73 19 6 2

= "A" - Can walk at home and outside; "B" - Can walk at home but with difficulties outside; "'C'" - Can walk at home but earmot outside; "D" - Cannot walk at all (stays in bed).

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However, the survey conducted most recently shows visible improvement in ability, although the age criterion of this study, lower than previously, accounts for these differences. It is also apparent that functional ability is differentiated significantly by gender (better ability among men reflects the fact that women live longer) and place of residence. Various studies have shown that inhabitants of rural areas, and particularly persons employed in agriculture, have better functional ability in old age than their peers from towns - in spite of the fact that all kinds of serious diseases are more common in rural areas (Gruszczynska et al. 1985). It seems that this discrepancy may be explained by several factors. Firstly, work in agriculture may prolong their functional ability in spite of the presence of various organic diseases. Secondly, it may be understood culturally. According to the rural ethos, a person's usefulness is based on physical ability, so it is desirable to maintain this ability as long as possible. Thirdly, functional ability is to some extent influenced by the fact that old people living in a rural environment have fewer architectural obstacles to mobility to cope with (stairs, means of transportation etc.). In general, one has to Conclude that the health situation of old people in Poland has deteriorated slightly over the last few years. This makes serious demands on social policy-makers and on the care system for the elderly. 2. THE ORGANISATION OF SOCIAL CARE

(a) The Legal Basis Social care in Poland is officially treated as "one of the elements of the social function of the socialist state and its administration" (Karczewski 1979). As such, it is the component of social policy which is responsible for appropriate satisfaction of the needs of all members of the society. Social help covers all the difficult situations experienced by an individual, which he or she cannot cope with personally by resort to his/her own means and resources. The right to enjoy help, however, is not a right which may be claimed in the legal sense. The range of services provided depends on assessment. Clients cannot demand anything on the authority of the law; they may only request assistance. In spite of this, social care institutions are obliged to show consideration for ensuring social safety for all citizens (Szumlicz 1987). The legal range of statutory social help in Poland was defined in 1923. At that time, this legalisation was very progressive. It guaranteed the satisfaction of basic needs at a minimum level. The obligation to ensure social help was primarily imposed on communal self-management bodies and on state organs, as auxilliary bodies. This legislation has not been declared void, nor has it been replaced by new legislation. In practice, institutions function on the basis of a plethora of regulations of the Ministry of Health and Social Care, which have multiplied in a haphazard fashion to fill out the gaps appearing in the social care

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- FORMAL

CARE IN CONTEXT

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system. In consequence, it is widely believed now, that the present legal status of social care is marked by regression in comparison with the 1923 act, whose formally binding character is now a total fiction (Lopato 1987; Szumlicz 1987; Szurgacz 1987). The present legal status and practice of social policy have been largely determined by Poland's turbulent history in the post-war period. Social care has been subjected to changing fortunes beginning with a period in which attempts were made to continue the progressive pre-war traditions (1945-1949), through a period (1950-1956) when it was seen as something alien to socialist principles and, finally, to the realisation of its need and importance even in a socialist state. The Stalinist period proved to be most detrimental to the development of social welfare. It was mistakenly assumed at that time that, with the development of the socialist system, social care would cease to be needed since political changes would automatically solve all social problems. In Poland, full recognition of the role of social help had to wait until the late nineteen-fifties. It was then that moves were initiated to establish its organisational foundations and structure, and to develop the directions and forms of further activity. Researchers have gradually become interested in this domain of social reality. Interest in the practical and theoretical problems of social care has grown in the present decade, during the years of acute socio-economic crisis.

(b) Forms of Help The system of social help for the elderly comprises at present the so called "community care" (financial help, material help and help in the form of services) as well as institutional care (social care homes). Financial aid is important since in Poland there is no national pension scheme (there is only a work-related pension scheme). There exist three forms of financial help: permanent allowance, temporary allowance and single payment. Permanent allowances may be granted to persons incapable of undertaking work who do not have retirement or disability pension fights, have no sources of income or relatives legally bound and capable of offering financial assistance (such allowance amounts to 80% of the lowest retirement pension). Temporary allowances are granted to persons who have temporarily found themselves in difficult financial circumstances and are available for periods not exceeding 6 months a year. Single payments are granted in order to cover specific needs. For instance, the purchase of food, heating material, necessary household utensils. Material help usually functions as an alternative to single payments, but may also be used as a separate available form of help. This help encompasses the following services: providing meals for dependent persons; providing food; distributing clothing coupons to be used in shops; providing clothing or footwear; arranging coal for heating in winter; help in obtaining means which could facilitate self-reliance (e.g. sewing machines). The main form of help in the area of services is care of an elderly person at

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home, organised and managed by the Polish Red-Cross (PCK) and initiated by the physician. This help is administered by nurses of the PCK and neighbours paid for their services. The services include basic care in the sphere of hygiene and sanitation, nursing help recommended by the physician and help in satisfying everyday needs. The second form of services is help offered by the Polish Committee of Social Help (PKPS). These services include various household chores performed by home helpers who do the house cleaning and shopping, prepare meals, feed disabled persons, do the laundry, provide the dependent person with heating coal and water and take care of various day-to-day matters. These services are charged for on the basis of the income of the dependent person. Social cam for elderly people in Poland, not unlike in other countries, strives to provide the elderly with means which would sustain them in the community for as long as possible. Persons who, due to disability, difficult financial situation, family conflicts or housing problems, are not capable of living on their own, in spite of obtaining different forms of community help are admitted to social care homes. In Poland, three basic types of homes for adult people exist: residential old peoples homes, nursing homes, homes for mentally handicapped persons. In Poland social care homes for the elderly house a relatively small percentage of the elderly generation - at present, the residents of all types of home constitute barely 1.4% of the total population of elderly people. Organisation of the above mentioned forms of social help is in the custody of the national administration, which in this area is the superior authority. Since 1960 social care has been organisatorally combined with the health services and has been under the same ministry. Responsibility for social and health conditions lies with political authorities and state administration at the basic level (the community) and the vivodship (provincial) level. Basic elements of the community help include: a district physician, a community nurse and social worker as well as a district social custodian.2 It should be emphasized here that this last element of the model is the only really voluntary element of the whole system of social care in Poland. However, the role of district social custodians in the overall system is constantly shrinking. Interest in this type of activity is clearly decreasing, the number of volunteers is falling and those who continue to be active are usually themselves elderly and often require social care! 3. COMMUNITY CARE The doctrinal underpinnings of social care, the analysis of its budgets and the results of research suggest that it is increasingly directed at extending help to the elderly generations, who are becoming the main target of its operation. It suffices to say that a poll carried out in 1985 by the GUS showed that as much as 19% of the respondents 60 and older received some form of social help in their life (but not necessarily in a given year). On the basis of a different case study and various small-scale research contributions it is possible to assume that,

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depending on the type of community, from 5% to 20% of elderly people receive some form of help from social institutions in every year (Frackiewicz 1985; Izdebski 1986; Wojciechowska and Czechowicz 1986). It is an optimistic fact that the society treats elderly persons with growing consideration and tries to satisfy as fully as possible needs, which in the past were satisfied by relatives, neighbours and communities. On the other hand, this phenomenon may indicate that elderly people are the least important population group for social policy-makers, if the functioning of this policy does not ensure the satisfaction of these needs. If it had been otherwise, we would not have encountered the problem of persons who have worked for many years whose income is insufficient to cover their basic needs. That this is the case may be demonstrated by the fact that in 1985 over 65,000 people received temporary allowances, while over 700,000 were granted single payments (Izdebski 1986). The above mentioned poll indicated that the most frequent form of help to elderly people was food provision ~ (71% of those who have availed themselves of any kind of social help); followed by clothing (35%) and medication (27%). At least one out of three recipients of help received financial support. Frequently help involved care during illness (18%) and doing household chores (11%). A comparable number of respondents received help in the form of free coal (12%). An almost insignificant percentage (2%) received free meals (Sytuacja 1985). The most important sources of institutional help in Poland are at present the state institutions of social care and the Church. Almost all the earlier analyses of social help for elderly people have been limited to the discussion of help offered by organs of the state administration, the so-called "Social Care Centers". The quoted GUS survey indicates that at present the largest proportion of the elderly receives help from Church organisations. The important role of the Church in providing help for elderly people is one of the signs of the growing status of the Roman Catholic Church and its importance in the socio-economic life of Poland in the nineteen-eighties. On the other hand, this fact testifies to the growth of new responsibilities for the social activity of the Church, which receives material assistance from various Church organisations and charities in the West. Polish society is predominantly Roman Catholic (90-95%) and receives different forms of aid from the Church. Although religious and moral reliance on the Church, as the sole institution in the country completely independent of the state administration, is important and universal, material forms of help also have a wide scope (Table II). This help is directed mainly at elderly people, as well as families with four or more children; families of prisoners of conscience; families of seriously ill people, etc. At present the Church provides a significant supplement to help offered by the state administration. The Church dominates in three areas of provisioning: food, clothing (footwear) and medicines. The scope of the activity of the Church in these three areas of help is several times that of state institutions. Other forms of aid (e.g. provision of orthopaedic equipment) for the elderly have a much more limited scope.

Source: Sytuacja (1985).

Social services Workplace Church Other organisations (in Poland and abroad) Remote relatives and acquaintances Relatives and acquaintances abroad

Types of institutions and organisations

61 14 8 17 -

19

10

Permanent allowance

22 9 35 5

Total

Forms of help

2

4

50 38 1 5

Single payment

10

8

11 3 66 2

Food

21

21

9 2 44 1

Clothing, meals

-

14

42 40 1 3

Heating, fuel

TABLE lI Some forms of help extended to the elderly by institutions and organisations (%)

19

7

17 1 36 20

Medicines

t==a 4~

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It must be said that social help from the Church is not systematic and it is not based on a detailed analysis of the real needs of elderly people. Due to large numbers of parishioners (some parishes have up to twenty thousand people) and the uncoordinated influx of commodities from abroad, the food or clothing is not always distributed amongst the most needy. Distribution of medicines, carried out in cooperation with physicians and pharmacists, is better organised. It seems to be necessary to move towards closer and more systematic cooperation between the Church and formal social care provision, but some cooperation does take place. Other than the family, the state care system continues to serve as the basic source of aid for elderly people. Its real importance is more significant than the figures in Table II seem to suggest. Although fewer people have received this help than help from the Church, it is directed to those in the most difficult circumstances. Furthermore, help coming from state institutions has been offered systematically, in many forms and for longer periods of time. Social services are almost the only organiser of free meals, nursing care and housekeeping help. On the other hand, Church help seems to be more eagerly accepted by most elderly recipients than formal service provision. The socio-cultural definition of such a situation and form of support is quite different from that of being a client of/he state social care system. Persons receiving help from social services are labelled "wards", which in social consciousness is usually associated with loneliness and helplessness. It is not customary to use the same word when talking about persons receiving help from the Church. The approval of the Church social assistance also results from informal ties of the recipients with other parish community members and reflects their religious attitudes and system of values. The relatively small proportion of elderly people receiving help from professional social services does not mean that the situation is good and the living conditions of the elderly are satisfying. On the contrary, the economic problems of the country endanger mainly the poorest sectors of the society. Pensioners slowly sink below the poverty line. The existing mechanisms for the re-evaluation of pensions do not effectively protect the elderly from the effects of galloping inflation. For example, in the period 1980--1986 the cost of living index grew by 380%, while pensions grew by 338%. The gap between these two figures spells serious deprivation for the elderly. A journalist who witnessed an old woman apologising to a shop assistant for not purchasing a kilogram of prepacked apples because of their high price, commented on this fact in the following manner: It's true that there has always been someone who could not afford something. And I don't have to make anyone aware of this. What I personally find depressing is the thought that the old lady could not afford to buy apples, the only fruit available in winter. I cannot afford apples either, but this is not important. As they say, young ones may but old ones must. So even if I am not a born optimist resignation from eating apples this year and maybe in several other years to go, is for me something quite different than for people

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who beyond eating practically do not have any other pleasures in life. There are quite certainly many more dramatic symptoms of impoverishment. It is often claimed that pensioners are the weakest, least resourceful social group, the most vulnerable to what is, deficient in our life. We should be prepared to encounter such scenes as the one with the apples (Wojewodzld 1987). The symbolic meaning of the above scene is corroborated by several research results. In a 1985 survey of a random sample of elderly people in the 60+ age group in Poland, 9% of respondents claimed that they had enough money to cover "only the cheapest food purchases and not enough to cover expenses connected with the purchase of clothing", and 5% claimed that "they did not have adequate income to pay for even the cheapest food and clothing" (Sytuacja 1985). Persons who live alone are in the most difficult material situation; in the older age categories almost half live below the poverty line (Tymowski 1986a). Why then, does only a limited percentage of elderly people avail itself of formal social help. This situation is a result of three factors, apart from the limited means of the social care system in Poland. First of all, elderly people in Poland usually receive considerable support from their families; mutual intergenerational help is an important element of family life in an ethos of family solidarity (Synak, 1988). Strongly entrenched cultural patterns of help, favouring concern for the situation of less self-reliant members, usually compels family members to deprive themselves of their own needs, rather than search for external aid. Seeking statutory care is defined as the "ultimate help" when all other means fail and when there is no other way out. Secondly, the elderly generation has a low level of expectation, especially in the material sphere. Many elderly people are convinced that they do not deserve much and that life does not have much to offer, at least in comparison with the needs of the younger generations. Material needs are reduced to the most basic commodities and services. Socialisation of these generations took place in the conditions of material deprivation of the war period and later in the difficult conditions of post-war reconstruction. At present, these same people find themselves in the complicated context of the overall socio-economic crisis. Concern over the future of their children and grandchildren overshadows their own needs. This is quite understandable in a country in which one must wait over twenty years to get an apartment, and in which some commodities (e.g. automobiles, colour television sets) are beyond the reach of a large proportion of the society. No wonder, that in self-evaluation of the elderly, we often encounter such opinions as" "somehow we can make ends meet", "it's difficult but it must make do", "others are even worse off" (Zbyszewska 1982). Thirdly, the limited domain of social help in Poland is a product of relatively inflexible regulations, based on the premise that it is primarily the duty of the family to ensure help and secure a proper standard of living for their elderly members. This is a consequence of the accepted behavioural norms, which are becoming a formal and impractical anachronism, barring numerous persons in distress from pursuing help from a social institution. Polish legislation contains a

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relatively wide range of different types of financial maintenance obligations. If children are incapable of personally offering help, they are obliged to cover expenses connected with securing that help from a third party. In practice, any help from children in such situations is left to their good will. If parents do not receive help, the court may order children to pay their parents specified sums of money to maintain their standard of living. Such cases, however, seldom reach the court, even if parents suffer deprivation and lack of help. Public discussion of family internal problems is, in the opinion of parents, an action which would be undignified in terms of family values. Furthermore, increasingly frequent are situations in which the children are incapable of fulfilling financial obligations because of their own difficult material situation. Thus, the present formalised and bureaucratised principles underlying social care for the elderly are a serious obstacle to its effectiveness, contribute to aggravating family relationships, and put potential clients of social care in a morally difficult situation. As mentioned above, in Poland one of the main principles behind social help is enabling elderly persons, for psychological, economic and humanitarian reasons, to stay in their own communities for as long as is possible. In consequence, help in the form of services and nursing offered to disabled and seriously ill persons is of the utmost importance. If this requirement is satisfied, it is only because this sphere of services is to a larger extent than other spheres subsumed under the system of help offered by relatives. Children may neglect other forms of support but when it becomes necessary to provide care for an ill or disabled mother or father, they try to fulfill that duty at any price (Synak 1987). Apart from a feeling of responsibility for the future of ill or disabled parents, an important role in this process is played by the culturally accepted values which specify the necessity to take care of ill parents, which are further strengthened by the pressure of social control stemming from the community, and strong religious norms. Parents, on the other hand, believe that "it is not fitting" to ask for formal care, when there are children around. Parents expect mainly financial assistance from institutions and they gladly accept it, while expecting help with household chores and nursing help mainly from their children and other family members. All research results confn'm that these expectations are to a large extent met. In a nationwide sample of elderly people less than 2% asserted that in case of a serious illness they would expect help from professional nurses (Sytuacja 1985). Detailed analysis of the forms of social help showed that only 0.5% of elderly people (65+) in reality receive nursing care from PCK nurses or PKPS home helpers (Wojciechowska and Czechowicz 1986). From a random sample of disabled persons the following responses were obtained to the question: "Who should I count on in ease of need?"; family - 68%, neighbours, acquaintances, friends - 21%; PCK nurse, PKPS custodian - 10%. It is symptomatic that the same number of respondents as in this last group (10%) claimed that they could not count on any help, unless it was "Divine Providence" (Zbyszewska 1982).

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Most clients of social care in Poland, therefore, are persons without relatives capable of fulfilling financial maintenance obligations. These people are given priority over others. Due to a lack of professional personnel, elderly people who have relatives living in the same town or village are ferquently not included in a social care scheme even if they actually need nursing or household help (Parafiniuk 1986; Czechowicz and Osada 1986). In consequence it is this category of elderly people which finds itself in the most difficult situation and it is in this category that we find persons counting on "Divine Providence". When the family fails to fulfill its obligations or when the situation of the children is such that they cannot ensure everyday care, then it frequently turns out that social help is unavailable as well for "second category clients". Quite often such cases are not even examined by social institutions since it is generally accepted that children should provide their parents with support (even most social workers think so!). Elderly, disabled persons are left to themselves, to struggle against adversity. These duties which the family fulfills with increasing difficulty or cannot fulfill at all, are only inadequately available from preventive and substitute moves made by the social care system. The main role in "community care" is to be played by units of the "Primary Health Services" which consist of" a regional physician, a community nurse and a social worker. This three-person team is responsible for organising all the medical and social operations in a given region (in the countryside a health region coincides with a local community). To realise these tasks, this team can rely on PCK nurses and on PKPS home-helpers. Elderly people usually have no qualms about accepting medical-nursing care at home, whenever such help is necessary. Well organised nursing care helps to improve an elderly persons' disposition, and lowers feelings of apprehension and distrust for others. A very important issue, which is also considered vital by recipients of medical aid, is contact with the same physician and nurse. In the present state of affairs, due to personnel shortages, this requirement is seldom met. Any discussion of the system of care of elderly and disabled persons in Poland must mention the hospice movement, which was established in Gdansk in 1984 on the initiative of the Roman Catholic Church (at present this movement is developing in other cities also). The hospice movement, as a domiciliary service, specializes in coping with the difficult problems of our under-invested and very imperfect social care system, as well as with some culture dependent issues. Care consists of giving different forms of aid to the family, to enable a terminally ill person to end his/her life at home in a family setting, if he/she wishes to do so. The Gdansk Hospice is based on the idea of Samaritan participation and is free of charge. Each team consists of: a physician, a nurse, a so-called "volunteer", a student of medicine, a priest and a nun. A hospice team extends full nursing, psychological and spiritual care to patients and their families. In Poland, there is a great need for the development of community social care, which is now infinitesimal when compared to financial assistance and which

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satisfies at best only a fraction of needs. This is all the more important, since the resources of the family have all but been exhausted. Women of working age, who have heretofore been the main resource pool of care, are now overburdened with housework, family problems and employment, while the number of persons requiring help is constantly growing. This growing burden is exemplified by the fact that as soon as (in 1983) it became possible to take paid and unpaid maternity leave, about 800,000 working women took the opportunity of going on such leave. At present, in consequence of the sharp rise in the cost o f living, the number of working women is again growing, amounting to about 80% of all women of working age. The undermining of the potential of the family to help its less independent members, coupled with the inadequacy of community social and nursing services, leads more and more frequently to a situation in which the only solution available in the case of an elderly person is placing him/her in an old people's home. 5. OLD PEOPLE'S HOMES When we say that old people's homes are that particular form of social care which is used only as a last resort, we mean that such are the formal criteria of admission to these institutions and that such are the cultural attitudes towards them that very rarely is admission to one of these homes a result of free choice. Usually the decision to move to an old people's home is a result of necessity. It should suffice to say that among persons waiting for a place at a nursing home as many as 70% are completely incapable of surviving on their own and within this group about 30% are bedridden (Wisniewska 1986). It is quite evident that social attitudes to this form of help are largely a result of the shortage of places in old people's homes and, resulting from this fact, the necessity to wait for long periods of time in order to become a beneficiary of these institutions. The waiting period is usually at least two years, and often much longer. Thus, only the most difficult cases are admitted to institutions and some old people, aware of the shortage of places, do not even apply for admission, in spite of their difficult living conditions. The most serious obstacle to the rehabilitation function of old people's homes is the very limited possibilities of transferring disabled and ill persons from residential homes to nursing homes, due to a particularly acute shortage of places in these latter institutions. In consequence, residential homes become nursing homes, and the difference between these two types of institution is in practice fictitious. When we supplement this bleak picture with the information about the nursing staff shortage and the disastrous state of repair of the buildings, then this form of care can hardly be claimed suitable for elderly people. It is more akin to a drab waiting room on the last station of one's life road, rather than the golden autumn days of a well deserved life's rest. It is beyond any doubt that in Polish society this situation reinforces the prevailingly negative attitude towards spending one's old age in an old people's home. This is

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especially prevalent among the elderly, only 1% of beneficiaries of home nursing care offered by PCK nurses, wanted to be institutionalized in the future in old people's homes (Parafiniuk 1986). It should be stressed that, contrary to expectations, candidates for residential homes are not usually recruited from recipients of social care. The above quoted work by Wisniewska shows that among persons waiting for admittance to an old people's home only 8% had earlier received help from PCK nurses, and 4% services from other social institutions. The vast majority consists of people who are for the fn'st time in their lives applying for any kind of formal care and who must wait for this help for years. For this very reason, it is difficult to view this form of help as an integral element and another link in the chain of help for the elderly, a link which may be made use of after all other forms of help for elderly persons in the family and community fail. Previously, the social stigma attached to this kind of help resulted in it being made use of primarily by lonely persons without close relatives. However, recent research conducted among persons waiting to be admitted to old people's homes in Warsaw proved that 65% of the surveyed persons lived with their families (a spouse, children or more remote relatives) and in spite of this fact had applied for a place in an institution (Wisniewska 1986). This situation is usually not the result of relatives' aversion to helping their dependent close kin. Neither is it a product of intergenerational conflicts. The primary reason is lack of means to cope with the duties connected with helping the elderly and disabled. This inability to help parents is usually a consequence of having too many duties connected with employment and bringing up children. Another important reason involves the difficult housing situation. In the case of elderly people, the problem is not only the small size of apartments and their over-crowding, but also the lower standard and Ix)or state of repair of apartments inhabited by the elderly. Most apartments occupied by elderly persons are located in old buildings, without basic facilities: 25% do not have running water; 60% are without central heating; 40% lack W.C.; 46% lack a bathroom; 85% lack a telephone (Sytuacja 1985). In such conditions it is very difficult to ensure functional independence for an elderly person and likewise difficult to secure nursing help for a disabled or ill person. Housing conditions are thus one of the most serious factors forcing an older person to leave his original community for an old people's home. Children or relatives very rarely initiate moves aimed at directing an elderly person to an old people's home. Cultural aspects and social values play a decisive role in forming such attitudes. Reluctance to propose to one's parents relocating them to an institution, even when circumstances are difficult enough to favour such a solution, is usually a result of anxiety that such a move could be interpreted as lack of loyalty. The obligation of maintaining family loyalty is a part of family tradition, part of the accepted behaviour patterns, moral and religious norms. Anxiety connected with the potential reaction of the parents, their disillusionment or apprehension over such a proposal is equally important

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as anxiety over the potential presure coming from neighbours, acquaintances and more remote relatives. In Poland, if a mother or father is in an old people's institution, it is often said of his/her children that they "gave their parents away" to an old people's home, which is a pejorative comment. According to research on the attitudes of town dwellers to social welfare only 24% of young people and 16% of the elderly believed that it was "normal" to send elderly and terminally ill persons to social care institutions (Wodz 1985). I recently discussed the problem of social control in one of my university classes and asked my students to give an example of behaviour which in our society would be negatively assessed. Their first example was that of the decision to place old parents in a "home for old people". I have myself experienced a situation in which my own assessment clearly reflected a similar system of values. How great was my surprise when, during a visit to a residential home in Finland, the man serving as my guide, an employee of the municipal social services, came up to one of the residents of the home, shook her hand and calmly introduced her to me as his mother. I was astonished by the behaviour of my guide, who took that situation as quite "normal" and did not see any reason to justify himself. Since that time I have become much less enthusiastic about the Finnish social care system, which previously had seemed almost perfect to me. I was depressed by the fact that such an institution could be accepted by both the generations as a natural solution for the elderly with children in a relatively good financial situation. At that moment, I no longer admired the high standard of living of old people in their residential care homes in Finland, by comparison with Poland, but ! was comparing the family relations in both countries. This example is a clear evidence of how attitudes towards residential care are culturally embedded. The above question is connected with a wider problem, the problem of attitudes offering social help in general. The present Polish model of protective action aimed at helping the elderly and disabled is clearly dominated by the "pro-family" tendency. This orientation pertains not only to symbolic culture (values, norms) but also to the structure of family life and in the context of its overall social setting. The Polish family is a relatively strong institution, resistant to external pressures and largely self-reliant. It has been strengthened by years of partitions and foreign occupations, by the period of disintegration of informal relationships and strong institutionalization of social life in the fifties, as well as by the present situation of socioeconomic crisis, against which the family is the most effective "protective umbrella" for its members. It is, therefore, hardly surprising that only a small fraction of Polish society prefers to obtain help from organized social care institutions and that social approval of such support is reserved mainly for the disabled and victims of natural catastrophes (Markowski 1986). Such an attitude is largely connected with the stigmatizing effect of social care. According to labelling theory (Kojder 1980), among some groups reliance on formal care is considered shameful and degrading, being an expression of failure in life and social degradation. This

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phenomenon is quite universal in Poland since as much as 37% of the clients of social care defined reliance on formal care provision as something unpleasant (Kazimierczak 1986). 6. ELDERLYPEOPLEIN HOSPITAL Although the process of ageing of the Polish society is not as advanced as in other countries, the phenomenon of the "geriatricization" of hospitals has been clearly growing. In the list decade frequency of hospitalization of elderly patients has grown by about 25%, compared with 15% for the whole society. The high proportion of elderly persons in the overall number of hospital patients is largely a result of the above mentioned health factors and also of the poorly developed national health service infrastructure. Lack of an adequate number of community nurses and home helpers, as well as the shortage of places in old people's homes, result in large numbers of elderly people being hospitalized, even if they require care rather than medical treatment. It is estimated that 10% of hospital beds in Poland are occupied by so-called "social patients", who do not require hospital treatment, but who remain in the hospital since no other ways of caring for them are available (Tymowski 1986a). This state of affairs is also conditioned by the difficult material situation of elderly people, who resort to hospitalization more frequently because periodic stays in hospital do not require covering expenses connected with heating, laundry etc. (Frackiewicz 1985). The health situation of the elderly is further aggravated by the fact that there is a serious shortage of hospital beds in Poland. Furthermore, the most severe shortages involve internal diseases wards and the programme of developing geriatric wards in hospitals has been shelved. Securing a place in a hospital is difficult and for elderly people very difficult. Although the health service in Poland is public and free of charge, securing a hospital bed, especially if the case is not urgent, often requires patronage and even bribery. An analysis of patients who had n o t been admitted to internal disease wards showed that elderly persons constituted 38% in this group (Putz and Mizikowski 1980). Underdevelopment of the national health service infrastructure influences both the relationship of medical personnel to elderly persons (who are often said to "block" hospital beds) as well as the attitude of elderly people to institutional medical help. Discrimination against elderly persons does not take place only at the moment the person is admitted to the hospital, but also during later stages of treatment. Too few physicians are trained in the treatment of this age group, and not all of them are ready to acknowledge the specific traits of aged organisms. In "competition" with younger patients the elderly usually lose and are treated as "second category" patients. One cannot find another explanation for the fact that beds standing in the corridors of overcrowded hospitals are almost completely occupied by elderly persons, so called "social patients". A fragment of an elderly patient's diary can serve here as a very good example: "If I ever think

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about death, I am especially afraid of human hell and more specifically hospital hell. I am afraid of interference and callousness . . . . " (Csorba 1971, p. 332). The words of Pope John Paul II at his meeting with the ailing and disabled in Gdansk seem to be particularly salient here: It is necessary to uphold at any price the beautiful Polish tradition: the work of physicians and nurses should be treated not only as a profession but also,~and perhaps especially, as a calling. Help for disabled and elderly people, help for mentally handicapped people, these spheres are more than any other spheres of social life, an indicator of the culture of a society and a state. Elderly people do not pester the national health service. They resort to medical help only when it is really necessary. The hospital becomes the "last line of defence" when the family and closest kin fail or cannot help, when one becomes lonely and disabled. For such persons, a stay in hospital is a real blessing, is the only way to solve the most serious problems of life. The attitudes of close relatives, who are legally obliged to take care of an elderly person temporarily staying in hospital, largely depend on the reason for hospitalization. In case of emergencies when the life of the elderly person is endangered, relatives demonstrate their emotional ties and concern over the patient's health. In the case of prolonged illness and old age disabilities (e.g. "social patients") we can sometimes witness attempts to get rid of nursing obligations by placing the elderly person in hospital and, by this means making it easier to obtain a place for him/her in an old people's home, thereby "solving" the problem. In such situations there is a marked loosening of emotional ties with the ailing person which tends to become deep-rooted the longer the patient stays in hospital. Families which send such elderly relatives to a hospital cannot or do not want to offer nursing care for their relative. Among those relatives who do not wish to be bothered by nursing their elderly relatives, some break off all their contacts with the elderly person as soon as he/she is admitted to the hospital (Kocemba and Podgorska 1986). It is difficult to estimate how often such a situation takes place, nevertheless it means that some Polish families have seriously weakened their protective functions. Those families seem to be quite outside of the influence of tradition and social control pressure, experiencing difficulties in adapting to cultural changes of the society (most of such families belong to the lower strata of the society). The large majority of families in Poland take care of their ailing and disabled kin as long as they can cope with such duties. An elderly person is sent to hospital only when all resources of family care are exhausted and when community nursing help is unavailable or limited. This tendency to bear the burden of caring for elderly disabled persons by their families is an outcome of the family group obligations and the state of social care system in Poland. There are such factors: on the one hand, the lack of places in hospitals and old people's homes and the poor state of the community nursing services, and on the other hand, widespread scepticism about the usefulness of seeking medical help in old

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age: "there is no cure for old age". Otherwise, it would be difficult to explain the fact that in spite of the growing percentage of elderly people and the shortage of places in medical institutions, the number of medical services has fallen and home visits of physicians have become less frequent (Frackiewicz 1985). Knowing the difficult situation in the health service, elderly persons often prefer to "give up" their struggle with illness and to stay home till the end of their lives, rather than wait in a long queue at a medical polyclinic, or compete for a place in hospital, especially if the elderly persons feel that they are competing with younger people. The remoteness of medical institutions from villages in the rural areas, as well as the strong influence of cultural traditions, result in the situation being especially unfavourable there. Rural areas are greatly disadvantaged in so far as medical care is concerned. The number of medical consultations per one inhabitant of rural areas is still three times lower than in urban areas (Lopato 1986). Some elderly farmers continue to be suspicious of institutional medical treatment and only reluctantly resort to such help. Perhaps the opinion of a Polish sociologist on the situation of elderly people in the countryside given below is somewhat exaggerated, but it is certainly not very far from the truth: A universal and, at present, very desirable method of medical treatment is hospitalization. Unfortunately, the placement of an elderly and especially lonely person in hospital is quite an achievement. The elderly persons themselves make such a decision when there is no other way out. Even severely ill persons prefer to stay at home and "die in their own place". They are also terrified of the prospect of leaving their household and farm "at the mercy of Providence". Quite frequently they are ashamed of showing to "strangers" in town the poverty and filth which they cope with in their everyday lives.

7. CONCLUSION Although the ageing of the population in Poland is not as advanced as in many other countries, there is a serious demand for supplementing the family protective function towards the elderly with formal care provision. The scope of social care, its forms and effectiveness reflect not the state of elderly people's health, but the wide economic and socio-cultural features of Polish society. The above analysis exemplifies the importance of the interface between cultural attitudes and values and social care provision. It shows that in Poland there exists a visible incompatibility between these two spheres. On the one hand the family is culturally and legally recognized as the institution which is responsible for caring for its elderly members. The approval of formal care depends on the family situation of the elderly. Residential care services are fully accepted only for elderly persons without children. Domiciliary services are of wider acceptance, however, they are approved as supplementary support rather than alternative help, replacing children's obligations. Financial allowances do not

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have such strong cultural implications as other forms of assistance. Receiving financial support from social care by older parents (especially in the present crisis) does not undermine the family group ethos and is accepted by both generations. Generally, formal care is recognized as an "ultimate" form of help, appropriate only in extreme life situations. The family is defined as the most natural resource unit for its elderly persons. Thus, according to the conviction of the majority of the older generation, receiving formal care (especially institutional care) reflects lack of loyalty to traditional family patterns and values. On the other hand, cultural changes, the growing number of dependent members, the deteriorating health situation of the elderly and the problems of everyday life seriously weaken the family's potential for offering help to its elderly members. As a result, at present there is a disjuncture between the need for help and the out-of-date inflexible legislation of formal care provision, which obliges children to ensure a proper standard of living for their parents. In this sense, the legal base of the social care system in Poland is more "conservative" than cultural attitudes of a part of society. Moves aimed at assisting a family group through a better system of social benefits, so that elderly persons can lead more dignified and secure lives - taking into account the cultural shifts as well as the children's ability to help their parents seem to be indicated. The analysis of the social care system for elderly people in Poland presents a rather grim picture. It would be difficult to claim that we are equipped with unified, reasonable, long-term social policy objective. Declared preferences and commitments connected with the needs and expectations of the elderly are not always reflected in concrete decisions, especially since the interests of old people are represented only by institutions of social welfare and no one else. According to Tymowski, "...nobody takes old people into account ... They function as petitioners and only petitioners, rather than as a pressure group. Their demands may be listened to, but do not have to be taken into consideration and be satisfied. This is why the problems of elderly people in Poland are often discussed but never solved. Old age policy fluctuates and is unstable" (Tymowski 1986b, pp. 622-623). Although the basic premises of social care are different, due to underinvestment in the medical infrasmacture and services, this care often takes on a "salvaging" character, that of an emergency measure. The system of help does not prevent situations in which an intervention is required and does not establish conditions which would allow elderly people to take care of their own problems in their own communities. This system ensures only occasional help without helping elderly people to reorganize their lives with the aim of returning to independent living in their own community, according to their cultural values and personal wishes. The system protects against biological death but not against "social dying". In consequence this situation leads to the problem of social alienation of the elderly, provides the foundation for an old age subculture, for disengagement, strengthening of negative stereotypes and further

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retention of apprehension and intimidation. The social care system has a centralized structure and the state serves as the total guardian, therefore, it would be more accurate to talk o f "state care" rather than "social care". This puts the s y s t e m ' s effectiveness in j e o p a r d y from the very outset, since an important feature o f an efficient system o f social welfare should be reliance on local, informal structures and self-help groups. The present structure o f the Polish state and the system o f social ties does not favour basing the system o f social welfare on lower structures. Between the family, as the basic element o f social structure o f the society, and the nation there is a conspicious gap, filled to some extent b y the Church. Therefore, it will not be easy in Poland in the years to come to realize the basic premise o f contemporary social p o l i c y to leave the elderly persons in their own homes according to their expectations.

University of Gdansk, Poland NOTES 1 During World War II about 6 million Polish citizens lost their lives. 2 A social custodian is an unpaid worker whose tasks include identification of social needs and cooperation with the formal care institutions. 3 The figures refer to only those persons in the surveyed group (19% who have been given some kind of help) apart from that given by spouses and children. REFERENCES Csorba, H. 1971 Ocena poziomu opieki nad lud~ni starymi w szpitalach w gwietle pami~mik6w. Szpitalnictwo Polskie. No. 15. Czechowicz, Z. and Z. Osada. 1986 Sytuacja rodzinna os6b w wieku powylei 60 lat a korzystanie ze gwiadczerl opieki spelecznej. A paper presented at the gerontological conference in Gdarlsk, September. Frackiewicz, L. 1985 Karta praw cztowieka starego. Warszawa: Instytut Wydawniczy Zwi+zk6w Zawodowych. Gruszczynska, G., W. Halicka, and W. Pedich. 1985 Sytuacja zdrowoma i spolecz na ludzi 19o 70 roku zycia we wsiach regionu bialostockiego. Manuscript. Izdebsld, M. 1986 Opieka spoteczna nad tud~mi starszyml. In: Warunld £ycia i problemy ludzi starych. P. W6jcik, et., pp. 258-296. Warszawa: Akademia Nauk Spotecznych. Karczewski, M. 1979 Opieka spoleczna. In: Polityka spoleczna. A. Rajkiewicz, ed., pp. 500-521. Warszawa: Parlstwowe Wydawnictwo Ekonomiczne. Kazimierezak, T. 1986 O stygmatyzujacym efekcie pomocy spelecznej. Prace Socjalna. No. 2. Kocemba, L and M. Podgorska. 1986 Rodzina w procesie szpitalnego i posszpitalnego leczenia ludzi starych. A paper presented at the gerontological conference in Gdagsk, September. Kojder, A. 1980 Co to jest teoria naznaczania spolecznego. Studia Socjologiczne. No. 3. Krzyzanowski, M. and B. Wojtyniak. 1983 Hospitalizacja os6b w wieku podeszlym w PoNce. Zdrowie Publiczne. No. 10. Lopato, J. 1986 Ludzie starzy na wsi. In: Warunki zycia i problemy ludzi starych. P.

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W6jcik, eel., pp. 517-553. Warszawa: Akademia Nauk Spolecznych. Lopato, L 1987 Podstawy prawne pomocy spolecznej. Praca i Zabezpieczenie Spoleczne. No. 2. Mar'kowski, R. 1986 Spoleczne przyzwolenie na udzielanie gwiadczerl przez instytucj¢ pomocy spotecznej. Praca Socjaina. No. 3. Parafmiuk, W. 1986 Opieka had chorym w domu. Pomoc socjalna. No. 3. Piotrowski, J. ed. 1973 Miejsce cztowieka starego w rodzinie i spoleczedstwie. Warszawa: Padstwowe Wydawnictwo Naukowe. Putz, J. and Z. Mizikowski. 1980 Hospitalizacja pacjent6w w wieku poproduk cyjnym w oddzialach wewnetrznych niekt6rych szpitali warszawskich. Szpitalnictw o Polskie. No. 24:5. Shanas, E. et al. 1986 Old people in Three Industrial Societies. Synak, B. 1987 The elderly in Poland: an overview of selected problems and changes Ageing and Society, No. 7. Synak, B. 1988 Family help for the elderly in Poland. A paper presented at the 12th International Congress of Anthropological and Ethnological Sciences, Zagreb, 24-31 July. Sytuacja bytowa ludzi starszych w 1985 roku, 1985, Warszawa, Glowny Urz~td Statystyczny. Szumlicz, L 1987 Rola i zadania pomocy spolecznej w ramach systemu zabezpieczenia spolecz. Model pomocy spolecznej. Praca Socjalna. No. 2. Szurgacz, H. 1987 Uwagi o ewolucji pomocy spolecznej. Praca i Zabezpieczenie Spoleczne. No. 2. Tymowski, A. 1986a Osoby starsze jako podmiot polityki spolecznej. Polityka starosci. In: Warunki zycia i problemy ludzi starych. P. W6jcik, ed., pp. 622-635. Warszawa: Ak~demia Nauk Spolecnych. Tymowski, A. 1986b Starsza kobiet w systemic ubezpiecze6 spotecznych. In: Spotecznopedagogiczna problematyka ~.ycia kobiety w wieku emerytalnym. Acta Universitatis Lodziensis, Folia Paedagogica et psychologica. University of L6d/. Wisniewska, H. 1986 Uwarunkowania przenoszenia siC ludzi starszych do domu pomocy spolecznej. Praca Socjalna. No. 4. Wojciechowska, Z. and Z. Czechowicz, Z. 1986 Warunki ~ycia ludzi starych i ich potrzeby w zakresie opieki w rodzinie. A paper presented at the gerontological conference in Gdadsk, September. Wojewodzki, T. 1987 Wesolo, "Dziennik Battycki", December 12th. Wodz, K. 1985 Pomoc spoleczna w gwiadomoffci mieszkarlc6w miasta. Katowice: Uniwersytet Sl~ski. Zbyszewska, Z. 1982 Problem ludzi niepehaosprawnych fizycznie. Zdrowie psychiczne. No. 34.