Senior Citizens' Care Services in New South Wales and Victoria, Australia, Now and into the New Millennium

Author: Dr Stephen P. Gatt O.A.M, J.P., K.M; M.D., L.R.C.P., M.R.C.S., D.C.H., M.A.S.C.H., M.R.A.C.M.A., F.F.A.R.A.C.s., F.A.N.Z.C.A., F.F.I.C.A.N.Z.C.A. (Head of the Division of An�sthesia & Intensive Care, Program Director of the Acute Services Programme, Prince of Wales, Sydney Children's & Prince Henry Hospitals, Randwick, Senior Staff Specialist, Royal Hospital for Women, Randwick, Senior Lecturer In An�sthesia, University of New South Wales, Kensington, Chairman, Board of Management, St Dominic's Hostel, Blacktown, New South Wales, Australia)

Introduction

To an old man any place that's warm is homeland. Maxim Gorky

At the time this report is going to print, we are coming towards the end of the International Year of Older Persons � 1999. It is appropriate, then, that the Convention of Leaders of Associations of Maltese Abroad and of Maltese Origin allocate some of its time to the plight of those Maltese migrants who are now of advanced or advancing age.

Our preoccupation with the aged is not one that consumes only the Maltese in Australia but also all the nations of the world for hardly any country is not faced with this new phenomenon � "elderly person explosion" � affecting the second half of the 1900s and the first half of the 2000s.

This problem has never happened at this level of magnitude before and will never happen again. What is even more perplexing is that the problem facing most nations is magnified several fold in those ethnic groupings with the body of migration (mostly, of young, healthy families) occurring in the late 1940s to mid 1960s � as happened from Malta to Australia, Canada and the U.S.A.

Global Demographics � The Big Picture

I advise you to go on living solely to enrage those who are paying your annuities. It is the only pleasure I have left.Voltaire

We are living through interesting times. An unprecedented phenomenon has struck our "cosmos". In our single working lifetime � all over the world � we will see more older people than ever in the history of our planet.

Perhaps, more astoundingly, we are currently in the middle of this explosion. This explosion is even more apparent in ethnic groups with large post World War II migration (like Malta) in countries who took those migrants (Australia, Canada, U.S.A.).

For over 400 years from 1540 to 1940, the percentage of elderly changed little (5-8%) so until the first third of the 20th century there were relatively few old people around.23 "There was an actual "younging" of the population from 1770 onwards so that at the end of the 19th century the English population was the youngest it had ever been on record" . . . "With effective Zero Population growth in the 20th century the percentage elderly" rose rapidly "but only reached the average for the past 400 years about 1930�40".23

Then came the surprise. The explosion in both percentage and actual raw numbers of old people started as a consequence of a major decline in mortality rates of the old. This explosion will be over in a century . . . and we are bang in the middle of it.

What makes old age sad is not that our joys but our hopes cease. Oliver Wendell Holmes, Jr

In those areas with high concentrations of Maltese-born residents (e.g. Blacktown and Holroyd, N.S.W.) there have been wide-ranging, local changes between the 1991 and 1996 Censuses which need to be taken into account when making decisions about the provision of services to the aged. In Blacktown, the population has increased by 9.7% with the overseas born increasing by 18.4% but the Maltese has decreased by 5.5%.1,12 In Holroyd, the population % change was +1.7, the overseas born +12.3 and the Maltese �13.7.1,12

Old age is not so bad when you consider the alternatives. Maurice Chevalier

Resources

In both Victoria and New South Wales, support for Senior Citizens from the Maltese Community has come from five main areas:

Religious Orders:
Dominican Sisters Of Malta
Missionary Society of St Paul
Capuchin Friars
Franciscan Friars Conventual
Franciscan Missionaries of Mary
Sovereign Military Order of Malta

Welfare Groups:
Maltese Welfare
Maltese Community Council
Transcultural Mental Health
Willyama Aged Care Day Respite
Older Persons' Consumer Health Forum
La Valette Maltese Respite Care
Migrant Resource Centres

Clergy:
Many individuals are involved in welfare, pastoral care to the aged, chaplaincy and hands-on care and counselling6,9

Government:
Federal and State Government heavily subsidise the Community Aged Care Packages1,4

Commercial:
In the past, these services were not prominent with the Maltese, but they are growing rapidly especially in the home care area2.

In the Overall Scheme of Things . . .

Time goes, you say? Oh no! Alas, Time stays, we go. Henry Austin Dobson

Maltese-Australians enjoy a formidable standard of living, have, in the main, done very well in their adopted country and enjoy the knowledge that their sons and daughters have done well for themselves11. Life expectancy continues to rise at a steady (some would argue, alarmingly) rate. Australian life expectancy is among the highest in the world � 75 for men, 81 for women.2

Many diseases of the Maltese elderly, such as ischaemic heart disease, hypertension and diabetes, can be controlled such that the long term effects are attenuated.1,25

Women live longer than men. There are 75 men for every 100 women aged 65 years and over and 40 men to every 100 women in the over 85 age group.2

Australians (and Maltese Australians) live longer; we are healthier; we live better; we have better facilities; we have access to greater financial resources.25

No matter how hard we try to paint a grim picture, 94% of the 65+ elderly in Australia today live in the community not in institutions. Of these 94%:

Are these Maltese-Australians Wealthy?

Poverty is an anomaly to rich people: it is very difficult to make out why people who want dinner do not ring the bell.Walter Bagehot

The 1966 Census figures show that, in today's money, the highest median earnings of Maltese in N.S.W. are between $A4, 160 and $A10,400 and the vast majority earn less than $A52,000. Very few earn $A52,000 to $A78,000 and only a minimal proportion earn >$A78,000.

Our experience in the Hostel (St Dominic's) in N.S.W. and the Nursing Home-Hostel (Rosary Home) in Victoria has shown that practically all allowable admissions classified as "Financially Disadvantaged" are Maltese elderly.

Even the Maltese who have done well have a great deal of their assets tied up in the family (often, matrimonial) home. There is considerable grief, due to the separation from ones neighbours, possessions and independence. This however is compensated by the security companionship and care one finds in a hotel, nursing home or retirement village.5,25

Accommodation for Older Citizens in Australia

The home of everyone is to him his castle and fortress, as well as for his defence against injury and violence, as for his repose.Edward Coke

A number of options are available to older Maltese-Australians wishing to leave the family home and live in a more protected environment.3 These include:

Supported Residential Services
Home Nursing,
Sociality Nursing,
Home Care,
Day Centres

Retirement Villages

Another, More Suitable Home
Moveable Unites (Rented Granny Flats),
Moving in with Relatives and Friends,7
Emergency Accommodation,

Hostel Care
Hostel Respite,
Hostel Living,

Nursing Homes

Hospital Based Care
Acute Care Hospital Beds,
Rehabilitation Hospital Beds,
Day Hospital,
Respite Care Beds.23

Services to Senior Citizens in Victoria

In three words I can sum up everything I've learned about life . . . It goes on. Robert Frost

Many Maltese-Australians Senior Citizens in Victoria are entitled to the following additional services3:

Victorian Pensioner Concession Card
Victorian College of Optometry Free Eye Examinations
Victorian Eye Care Service
Free Ambulance Service
Victorian Patient Transport Assistance Scheme including Concession Fares
Free Car Registration
50% off Council Rates, Water and Sewerage Charges, Water Consumption
Telephone Allowance
Waiver of Land Tax
Reductions of Exemption of Stamp Duty
Victorian Carer Service Network
Memory Management � National Ageing Research Institute
. . . but, many Maltese are not aware of the existence of these services.

Services to Senior Citizens in N.S.W.

Maltese-Australian Senior Citizens in New South Wales in the areas of highest Maltese-speaking aggregations have the following available services:

Geriatric Rehabilitation and Assessment Units
Domiciliary Nursing for the Elderly
Rent Assistance
Community Transport Service
Lump Sum Pension Advance7
Home Tutor Scheme
Dementia Home Support
Home Care and Home Maintenance Services
Geriatric Medicine Services
Aged and Disability Day Care Services
Legal Aid Centres
Meals on Wheels
Laundry/Linen Services
Seniors Information Services
Government Access Centres
Transport Concession Tickets
Concessions on local government rates, domestic waste charges and water and sewerage charges
Low floor Buses on all routes
Pensioner Housing Programme
Affordable Housing Kits (to builders)
Road Safety Strategy for the Elderly
. . . but once again few Maltese avail themselves of the bulk of these services.

Services to Senior Citizens Common to Both States

Some services, mostly provided by the Federal Government, are available to all Maltese-Australians3:

Aged Care Assessment
Aged Care Facilities � Hostels, Nursing Homes, Retirement Villages, Movable Homes (Granny Flats)
Seniors Card
Centreline
Interpreting and Translation Services
Commonwealth Concession Card, Pensioner Concession Card & Health Care Card
Multilingual Telephone Information Service
Pharmaceutical Benefits Scheme
Multicultural Community Organisations
Education Maintenance Allowance
Hospice and Palliative Care
Hearing Service Programme
Legal and Financial Assistance
Subsidised Dental Care
Retirement Planning
and a range of Older People's Organisations.

Many Maltese are not aware of these sevices available of them such as Home Care, Meals on Wheels or Respite and Day Care Centres.

The Problems Maltese-Australians Face in N.S.W. and Victoria

In his treatise "The Ageing Maltese � a Minefield of Need and Neglect", Lawrence Dimech, in a review of a sample of 200 Maltese in Western Sydney points out some problems peculiar to Maltese-Australians.11 He points out that many Maltese elderly live in isolation, boredom and even deprivation.

The Australian Welfare System assumed that the Maltese migrant does not have an "English language" problem, is culturally Anglo-Saxon.11

The Maltese migrant was almost as guilty when it comes to pointing the finger at the agent for future neglect. We integrated and assimilated well, we assumed a low profile, we made mush mileage out of our adeptness at the English language in the acquisition of a berth to Australia and employment (even though most migrants of the 40s, 50s and early 60s spoke little English and had little schooling), we rubbed in the truism that we were British subjects (and carried British passports as evidence) and we spread our families far and wide very quickly. We tended not to settle in discreet easily-identifiable groups. We were hardworking, quietly pleasant and sometimes quasi-subservient and did not wish to create controversy or draw attention. We were good citizens and keen to educate our children . . . and we did assimilate and integrate. And yet, seventy two percent of migrants had only primary school education and most could not even read or write Maltese.

What Proportion of Maltese-Australians Have Difficulty with the English Language?

Perhaps somewhat surprisingly, given that most migration from Malta had diminished to a trickly by 1972, the 1996 census showed that a full 18.1% of Maltese speakers aged 55+ in N.S.W. were poor English speakers and that this figure rose to 37% in those aged 75 years and over.26

This is elegantly shown in Table 2 published in the 1999 N.S.W. Statistical Profile.26

We Came Looking for Space and Freedom . . . and We Found It

Solitude is the profoundest fact of the human condition. Man is the only being who knows he is alone.Octavio Paz

The Maltese migrant came to Australia in search of employment, fortune , security and a "future". Most have found all those things and they, and their children, now reap the benefits of their efforts.14,16

We also came looking for space and freedom . . . and we found it. It is this space which now provides the prison of old age.13,14 The elderly cannot walk to their churches, clubs and entertainment.14

The whole of Malta is the same size as the Municipality of Blacktown � there are 40 municipalities in Sydney alone!! One Australia city is over 18� the size of the whole of Malta.

Planning services for a single ethnic group over these distances is a mind-boggling prospect.13

Only a few human beings should grow to the square mile; they are commonly planted too close.William T. Davis

Nevertheless, the situation may not be as grim as at first imagined. Dr Hal Kending's A.N.U. 1981�1986 Ageing and the Family Project showed that in Sydney in those with an elderly handicapped person, family support was, more often than not, readily available.

The Magnitude of the Problem

More than a third of Maltese-born Australians are now Anzjani 60+ years old.11 This means that we have over 50,000 Malta-born elder people scattered over an area larger than the Continental U.S.A. The sheer magnitude of the problem boggles the imagination.

Between 1947 and 1966, 52,000 Maltese settled in Australia and they are now 33 to 52 years older. Those adults and teenagers are either elderly or nudging retirement.1

The number of Australians over 65 years will rise from 1.9 million (11% of population) in 1990 to 5.2 million (20%) in 2031.

The Maltese elderly as a group are growing faster than most other ethnic elderly groups and, soon, more than 50% of Maltese-born people in N.S.W. and Victoria will be senior citizens.11,21 In 1989, the median age of the Malta-born in Australia was 42.3 years compared to the Australia-born median of 27.5 years.24

We have failed to present a plan to meet the future needs of our population.

The Health of our Maltese Elderly

Time goes by: reputation increases, ability declines. Dag Hammarskj�ld

A survey of 200 Maltese elderly showed that over 80% had coexisting disease with arthritis (36%) and diabetes (26%) being the most prominent.11

Common problems facing many of the Maltese elderly are loneliness, isolation, low self-esteem and loss of sense of worth, obesity, borderline depression, anxiety, embarrassment about incontinence and dementia/Alzheimer's.22,23 The recurrent tragedy is that of the lonely elderly (usually) women (they often outlive the male partner by many years) who is housebound with no access to transport and visited infrequently by her children.

Alexander Pope (1688�1744), on his deathbed, "I am dying, Sir, of one hundred good symptoms"

Health problems are compounded when the patient is either not fluent in English and cannot get to a Maltese-speaking doctor (or health carer) or is unable to remember instructions (e.g. taking of prescription medication).

The approaches to patient care must be relatively specific for the geriatric population but increased importance must be given to social and personal function.23 The concepts of threshold, summation and convergence must be kept in mind when dealing with the elderly.

It should be remembered that the amount of additional pathology needed to exceed the threshold for clinical presentation declines with age (e.g. onset of confusion when a new medication is started).23 Often, several subclinical pathologies summate to produce a clinical syndrome (e.g. more imbalance in late onset Parkinson's disease). Multiple pathologies can converge on one area of function to produce a single pathological picture (e.g. increased confusion in the blind or deaf patient with dementia).

Dementia is the most devastating of the disorders "of old age". The combination of altered personality, behavioural changes (suspiciousness, paranoia, wandering, disinhibition and aggression), incontinence, apathy and inertia make for a formidable combination of needs for the carer.15 There are many causes of "dementia":

On the other hand, we must not underestimate our Maltese elderly. Slower thinking and remembering is not necessarily less accurate. Also, it is not always cognitive impairment that cause communication problems; sometimes, it is due to an inability to see or hear adequately.23

Principles of Management of the Maltese Elderly

I hear and I forget. I see and I remember. I do and I understand. Chinese Proverb

Bitter experience has demonstrated that the Maltese elderly

prefer to live and die in their own homes,11
will not voluntarily enter aged care facilities so that only 7% of our aged live in "institutional care",
wish to be close to their children and will not be separated from relatives by the tyranny of distance,
assume all too readily that the extended family structures extant in Malta will support them in old age, only to be disappointed when children move interstate or overseas (sometimes, even back to Malta),
are reluctant to accept hostel or nursing home care,
are suspicious of hospitals,
are accepting of care offered not by lay people but by religious, especially Maltese, nuns (71% would go to a hostel run by Maltese nuns),
will not necessarily use a service when it is provided, even when it is free, value-for-money, cheap or "doable" on the pension.

Planners of "institutionalised" services must

concentrate on the social model of "home-like" care with emphasis on the Maltese way of life (e.g. the recreation of the equivalent of iz-zuntier tal-knisja);
understand that the majority (72%) of Maltese elderly subsist on their pension and that only 16% have additional means;
provide small, personalised, locally-accessible services (e.g. Maltese clusters) rather than monolithic, centralised, "easy-to-administer-and-manage" but "of-no-use-to-more-distant-communities" white elephants;
accept that the Maltese elderly, even the well-aged ones, are less likely to join in activities and access services of all sorts including diversional and occupational activities within the clusters, homes or hostels than their "Australian-born counterparts. Unfortunately, the latter is a trait etched into the Maltese psyche which is aggravated by increasing age;
understand that the commonest entertainment for the Maltese aged is T.V. (83%) and Maltese radio (58%)11 and, of course, "conversation" with fellow Maltese;
accept that financial considerations are of primary importance to the aged and their families. Loss of the family home takes precedence over independent living and improved care facilities in their old age. 78% own their own dwelling. Planners must be cognizant that retirement planning is often non-existent or poorly understood;
recognise that many of the activities in a hostel or nursing home have to be promulgated by word of mouth because of the high level of illiteracy among the Maltese-born;
plan to spread community and Government largesse, scant as it is, over wide areas of our metropolises;
remember that, somewhat counterintuitively, the oldest and frailest of our Maltese live in the inner metropolitan area, albeit spread over several local council areas, not in the West of Melbourne or Sydney as the initial, more superficial, demographics would suggest.

What can This Summit Conference Achieve?

We only think we are confronted with a problem.John Dewey

This forum needs to affirm that older Maltese Citizens

are entitled to and deserve ethnically-appropriate services for the elderly;
need culturally and linguistically appropriate advice regarding their options and rights;
need Maltese-specific services � diabetes care, podiatry, optometry;
deserve Maltese-specific activities � bocci, pasturi, ghana, festi, banda, vari;
crave Maltese food � pastizzi, timpana, ravjul;
are entitled to the company of their peers when they become old, solitary and frail;
need to have simple structures in place which lists them on National register when they become not only old but also solitary, so that their community, spiritual and health needs can be attended to;
demand equal access to native-born Australians' services,
need information in Maltese of the services available to them on the ethnic radio services.
What can the Maltese Government, the Church in Malta and the People of Malta do for its Sons and Daughters?
Men may be linked in friendship. Nations are linked only by interests. Rolf Hochhuth
The Maltese older citizens need
- ongoing support from the Maltese clergy of our people's Catholic faith and spiritual needs;
- facilities in Malta for those who wish to retire to Malta in their old age;
- establishment of a special service to help resettle the Maltese elderly returning to Malta;
- young welfare providers with good Maltese-language skills sent by the Maltese Government with the express aim of establishing links between the aged individual and the available facilities.22 These Maltese social and community workers will act as "champion and mentor" of the Maltese senior citizen. These individuals could be outsourced from the High Commissions, the Embassies or the Consulates or be seconded directly from Malta to the voluntary Welfare Associations;
- a simplified passport extension and issue service specifically for Maltese-Australian elderly wishing to repatriate to Malta. The current paper trail is endless � a bureaucrat's paradise. A simplification and easing of citizenship and dual citizenship and bilateral agreement (especially pension) regulation and interpretation would be most welcome; an added bonus would be continuous (say, 10-15 hours per day) transmission on our own Maltese ethnic radio station aimed at ongoing education and cultural enrichment.
Conclusion
As in all countries, including Malta, the problem of the ageing population is a complex one which cannot be resolved using a single formula. Indeed, it is one that will not disappear simply by "throwing money at it". It requires the dedication, devotion and persistence of many thousands of people � mostly volunteers, the religious and family members.
Nevertheless, the families, the Government agencies and the community have a shared vested interest in the care of our elderly. Most are "someone's" parent.
I trust that we will not walk away from this Summit in a few day's time without having asked the Maltese Government for, at a minimum, two enhancements:
(1)a scheme which will allow and assist the repatriation of elderly Maltese,
(2)assistance in the setting up of a network of small offices across the country designed to offer basic legal, retirement planning, health (including grief counselling) and accommodation options advice and to act on behalf of the elderly when more sophisticated facilities and services (palliative care, rehabilitation, respite care, hospice, dementia services, nursing home placement) become necessary.
I have no illusions about the Maltese Government's ability or willingness to invest heavily in these infrastructure projects. It has neither the resources nor the corporate will to do this. Nevertheless, it must be understood that what I am putting forward is neither an expensive monetary exercise nor a huge bureaucratic task. Indeed, what we are asking for is less bureaucracy, a Malta centre for expatriate elderly (funded mostly, I suspect, by overseas pensions) and a few Geographically well-placed Maltese or Maltese-speaking individuals with "local" knowledge in Australia, Canada and the other aggregations of Maltese expatriates to specifically take care of the needs of the Maltese elderly.
Every man who says frankly and fully what he thinks is doing a public service. Leslie Stephen
References
1.Strategic Plan � Serving the Non English Speaking Older People: Western Sydney Health 1999�2000 Area Multicultural Health Unit, 1999.
2.N.S.W. Healthy Ageing Framework, 1998�2003: Ageing and Disability Dept., N.S.W. Health, 1998.
3.Positive Ageing Team, Aged Care Branch, Victorian Department of Human Services. A Guide to Services for Older Victorians. Dept. Of Human Services, Melbourne, 1998.
4.Aged and Community Care Division, Dept. Of Health and Family Service: Aged Care � Make the Decisions That Are Right for You, Quality Care for Older Australians, Canberra, 1999.
5.Mascari A.F.: Old Age � The Loss and Grief of Losing a Home. Degree Assignment for Lees, P., personal communication, 1998.
6.Dimech L., Caruana M.: Maltese Resource Directory � 1996, La Valette Social Centre Inc. And Maltese Welfare (N.S.W.) Inc., El Faro Printing, 1996.
7.Dept of Social Security: Home and Residence Choices for Older People. Information and Help from Social Security, Centreline, Veterans' Affairs and Health and Family Services, Canberra, 1997.
8.The People of New South Wales � Statistics from the 1996 Census, Australian Bureau of Statistics, Ethnic Affairs Commission, Sydney, 1998.
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10.Strategic Plan � Serving the Non English Speaking Elderly Population: Western Sydney Health 1998�2001, Area Multicultural Health Unit, 1999.
11.Dimech L.: The Ageing Maltese, 1999 � A Minefield of Need and Neglect, La Valette Social Centre, 1992.
12.Amendments to the Citizenship and Immigration Laws, Question and Answer, Dept. Of Information, Expatriates and Nationality Division, Office of the Prime Minister, Valletta, Malta, 1990.
13.Information on Migrants in N.S.W. including Census Data and Statistics from the D.I.M.A. Settlement Database, Settlement Planning Unit, Dept. Of Immigration and Multicultural Affairs, Sydney, 1998.
14.Troisi J.: Seminar on Ageing, La Valette Social Centre, 1997.
15.Broe A.: Organisation of Services for Alzheimer's Disease, Australian Rotary Health Research Fund 3rd International Conference, Australian National University, Canberra, 1988.
16.Various Authors: Maltese Elderly in Australia, Thanksgiving Day Seminar, 1994.
17.Carter G.W.: Ageing and the Cardiovascular System: The Gerontology Foundation of Australia Inc., 1989.
18.Broe G.A.: Demography of Ageing: Social and Economic Implications, Geriatric Assessment Unit, Concord Repatriation General Hospital, 1989.
19.Inner West Geriatrics and Rehabilitation Service � an information Package, Central Sydney Area Health Service, Sydney, 1996.
20.Bishop B.: National Strategy for an Ageing Australia, Office for Older Australians, Dept. Of Health and Aged Care, Canberra, 1999.
21.Cauchi M.: Maltese in Australia, Maltese Community Council of Victoria, Gozo Press, Malta, 1990.
22.Mascari A.: The Maltese in Sydney and the Metropolitan Area. Personal communication, 1999.
23.Broe G.A., Creasey H., Sefton A., Horsburgh G., Kennedy P., et. al.: Geriatric Medicine � Lecture Notes, Uni. of N.S.W., 1999.
24.Borg V.: The Maltese Aged � A Study, Seminar on Ageing, 1991.
25.Director of Health Services Policy: The National Strategy for an Ageing, Australia � Healthy Ageing Discussion Paper, Office for Older Australians, N.S.W. Health Dept. Sydney, 1999.
26.Older People and Cultural Diversity: A Statistical Profile 1999. International Year of Older Persons 1999. Ethnic Affairs Commission of N.S.W., Sydney, 1999.