Introduction

When discussing this book with colleagues and students, people were generally excited by it and said that there was a real need for such a book. Almost everyone, particularly those in the UK, had a fairly similar argument for why this was important which went something like this: i) the family has traditionally been the main source of care for older adults in India, ii) tradition mandates that daughters-in-law will move in to the family home with their husband and assume caring responsibilities (for all generations), iii) modernisation and migration are destabilising these traditional living arrangements as adult children, in particular women, move for education and/or work, iv) in the absence of any old age social security programs older adults will be unable to get the care that they need and instead face years of disability, depression and loneliness. There is definitely more than a kernel of truth in this accepted narrative about changing living arrangements and care for older adults in India. Families are mandated to take care of their older members through the Maintenance and Welfare of Parents and Senior Citizens Act of 2007. This act empowers any ‘senior citizen including parent who is unable to maintain himself [sic] from his [sic] own earning or out of the property owned by him [sic]’ to apply for support from their relatives who are then obligated ‘to maintain a senior citizen … so that [they] may lead a normal life’. Failure to do so can result in fines or imprisonment. This Act is often taken to underscore the centrality of the family in India and seen to represent the government's attempt to shore it up in the face of challenges such as migration and modernisation. Again, such concerns are not without merit. As has been noted earlier in the book the scale of internal and international migration in India is staggering. There are estimated to be 450 million internal migrants within India and a further 18 million Indians who live abroad (De, 2019; UNDESA, 2020). Alongside this, as the data presented by James and Kumar (Chapter 3) and Rajan and Sunitha (Chapter 5) show, around a fifth of older adults do not live in households with extended families. For many older Indians this represents the decline of traditional values and is something to be lamented.

Introduction

This chapter provides a theoretical framework to understand the ways in which living arrangements and the provision of care for older people in India have been affected by migration. According to the United Nations, as of 2020 nearly 18 million Indians were living outside their country of origin. Indians are the largest diaspora groups followed by Mexican, Russian and Chinese diasporas (UNDESA, 2020). The largest concentration of Indian international migrants is in the Gulf region. The international migration from India prior to 2000 was largely low skilled and more focused towards the Middle East. After 2000 rapid globalisation increased the migration of skilled workers to the developed countries. Much of this skilled migration was among middle-class households and followed a trajectory where education and employment mobility to cities fuelled further migration plans to other countries. Indian migrants also contribute a large portion of their incomes as remittances. According to the World Bank, India received close to $US84 billion as remittances in 2019, close to 2.8 per cent of its GDP. Due to the COVID pandemic the World Bank estimates that remittances could drop by between 7 and 9 per cent (Ratha et al, 2020).

However, as eye-catching as these figures are, it is important to remember that the number of internal migrants within India is far greater than those who migrate abroad. Increasing urbanisation, improvement of travel and access to travel, coupled with greater educational opportunities, has led to widespread migration within India. Migration to the cities is driven by a combination of labour migration, which can be both temporary and circular, educational mobility and marriage migration. Bhagat's (2016) analysis of the 2011 census data shows that nearly 30 per cent of the Indian population moved internally. De (2019) reports that there were 450 million internal migrants in India and much of this migration was intra-state migration. See Chapter 3 by James and Kumar on the impact of migration on living arrangements of older adults in India. The lower levels of interstate migration could potentially be due to the non-transferability of social security entitlements across state borders (Kone et al 2018).

Introduction

India has one of the most rapidly ageing populations on the planet. Given the change in the size and nature of the older population in India it is imperative that we better understand the situation of older people in India. However, India is a complex and diverse country made up of different states, castes, cultures, and ethnic groups. India's older adult population has now risen to 8.57 per cent, however in states such as Goa and Kerala the percentage of older adults is as high as 11.20 per cent and 12.55 per cent respectively (Census, 2011). Recent data from the Longitudinal Ageing Study in India (LASI) show that nearly 12 per cent of older adults were 60+ and that the states of Kerala, Himachal Pradesh, and Tamil Nadu had a higher proportion of older adults (IIPS, 2020). India had, in the past, a predominantly familybased elder care system. However, rapid population ageing, the decline of extended families coupled with decreasing fertility rates, increasing life expectancy, widowhood, singlehood or strained intergenerational relationships, have all raised concerns that an increasing number of older adults in India live alone. These concerns are amplified as India, like many other lower-and middle-income countries, is still struggling in setting up social security and pensions systems (Arokiasamy and Yadav, 2014; Giridhar et al, 2014; Bloom et al, 2015). However, as we show throughout this edited volume, the demographic picture is not uniform as Indian states are at surprisingly diverse levels of demographic transition and vary to a great extent in their cultural practices, social norms and socio-political contexts.

This chapter provides a general introduction to the topic by situating the subsequent chapters within the broad demographic trends already mentioned and gives an outline of the structure and chapters of the book. This chapter introduces the need for focus on living arrangements and care. It highlights the social, economic and cultural contexts that shape the provision of care for older adults. We link the different studies presented and explore the consequences of changing living arrangements on long-term care, and the economic, physical, social and psychological well-being of older people.

Introduction

Work is necessary to provide people with the means to live healthily, but since time immemorial, it has also been obvious that work can harm people's health through occupational accidents and the wear and tear of heavy and repetitive physical labour. It is far less obvious, but not necessarily less important, that work can also harm through chemical, social and psychological exposures. In this chapter, we will discuss how psychosocial factors at work can impact on people's health, and how such factors have been conceptualised and measured by researchers in this field. For decades, technological development has meant that fewer people work in agriculture, that factories acquire more modern machinery, and that increasing numbers of people work in office and service occupations – for example as salespersons, computer programmers, call centre operators and nurses. As described in Chapter 4, this is also increasingly true in India. Related to this is a decrease in physical work injuries. At the same time, the development of vaccines, antibiotics and good hygiene practices have helped to reduce the relative burden of infectious diseases. In contrast, cardiovascular disease, diabetes and cancer have become more salient as causes of death (Lonzano et al., 2012) and disability more globally (Murray et al., 2012). These are diseases which are known to be affected by health behaviours and are also believed to be stress related. Mental and substance use disorders, while contributing relatively little to premature mortality, are now the leading cause of years lived with disability worldwide, with depressive disorders contributing about 40% of this burden of ill health (Whiteford et al., 2013). These disorders are also commonly held to be stress related, and thus likely to be affected by the psychosocial work environment. A 2006 study, part of the World Health Organization (WHO) Global Burden of Disease studies, reported that 8% of depression globally can be attributed to environmental factors, in particular occupational stress (Prüss-Üstün and Corvalán, 2006).

It can therefore be argued that psychosocial factors are likely to have gained in relative importance for public health, at least in industrialised welfare states. The situation is less clear in developing countries, where a large proportion of the population still works in agriculture and physically demanding factory work, and where issues such as malnutrition, lack of clean water and poor access to healthcare are still salient for substantial parts of the population.

Introduction

India is one of the fastest growing economies in the world (Gupta et al., 2014). Although growth in gross domestic product (GDP) has been quite volatile at times, India has still maintained an average annual growth rate of more than 7% since 2000, even reaching double-digit growth in 2010. This compares with just over 2% in the UK over the same period (World Bank, 2016a). The growth of the Indian economy has been matched by the steady increase in its labour force, which has risen from 330 million in 1990 to nearly half a billion people in 2014. This is roughly double the size of the labour force of the entire European Union. Not only has the workforce grown but it has also changed from one dominated by agriculture to one with vibrant and growing service and manufacturing sectors (World Bank, 2016b). Yet, despite drawing hundreds of millions of people into work and reducing levels of absolute poverty it is estimated that there are still 600 million Indians who lack access to necessities such as clean drinking water (Gupta et al., 2014). These privations are most keenly felt by those who are already in the most disadvantaged positions in society, such as poor people, wage labourers, agricultural labourers in rural areas, Scheduled Tribes and Scheduled Castes (Kumar, 2015). As Dreze and Sen (2014) critically note the benefits of India's tremendous economic growth have been unevenly distributed across society.

The same is true of developments in the health of the Indian population. On the one hand, there have been great improvements across a wide range of health indicators. Life expectancy has risen steadily for both sexes, largely owing to falling infant and maternal mortality rates. Life expectancy in India today (about 66 years) is more than twice what it was in 1951 (32 years) and infant mortality is about a quarter of what it used to be – 44 per thousand live births today as opposed to 180 or so in 1951 (Dreze and Sen, 2014). Infectious diseases have declined over the past few decades with some key diseases, such as maternal and neonatal tetanus and polio, being eliminated or even eradicated (Centers for Disease Control and Prevention, 2015; Narain et al., 2015; WHO, 2015).