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3 1 Growing Old in a City Life . . . is a sort of splendid torch which I have got a hold of for the moment, and I want to make it burn as brightly as possible before handing it on to future generations . . . the true joy in life, being used for a purpose recognized by yourself as a mighty one; the being thoroughly worn out before you are thrown on the scrap heap, being a force of nature instead of a feverish, selfish, little clod of ailments and grievances complaining that the world will not devote itself to making you happy. —George Bernard Shaw, Man and Superman How does one grow old in a city? Many New Yorkers, and residents of other major metropolitan areas, might say that you don’t. Instead, they might say that in such a place you live a full life, like that which Shaw describes in Man and Superman, full of the energy of a center of such lives. For the out-of-towner, growing old or, in the language of gerontology, “aging in place,” in New York City may seem absurd. The more than 30 million visitors who flood New York City each year (Better Business Bureau 2002), rubbing shoulders with its 7.4 million inhabitants, may find it an exciting place to visit, but they may also wonder why one would choose to grow old in New York City. Why, in particular, would one choose to remain in the city when just managing the simple tasks of daily living requires the caring and kindness of strangers, and quiet space for leisurely living and perhaps even the kindness of strangers are in more ample supply elsewhere? Some elderly New Yorkers do leave, but most New Yorkers live out their lives in the city. They do so not as a result of conscious decision but as a consequence of simply continuing to live their own lives. So it is with the way care is organized for the frail elderly in New York City or anywhere else. There is no central master plan. The elderly 4 Reinventing Care and the informal and formal providers of their care simply invent ways to deal with the immediate circumstances they face. This chapter catalogs the pieces that make up the large, constantly evolving, complex system that cares for the frail elderly in New York City: the population that system serves, the providers caring for that population, and the ways their care is paid for. The Population Migration and dependency patterns determine how many people need long-term care in New York City. There are about one million people over the age of sixty-five living in the city’s five boroughs (Claritas 1998). About one third of them live alone, and more than one fifth have mobility and self-care needs. The more than 139,000 persons in New York City over the age of eighty-five comprise the largest portion of those with mobility and self-care needs and of those who reside in nursing homes. In the United States as a whole, those over eighty-five are the most rapidly growing age group. In New York City, the eighty-five-plus population grew by 10% over the last five years. The financial resources of New York City’s elderly determine the kind of care they are able to receive. About 63% of households over sixty-five in 1990 in New York City had household incomes of less than $25,000 per year, far less than the annual cost of personal care. The ethnic diversity of the city shapes the availability of informal family caregivers and the character of the formal care that is provided. Foreign-born and second-generation immigrants account for 60% of New York City’s population. Blacks, Hispanics, Asians, and nonnative persons accounted for 84% of the city’s population in 1998 (Waters et al. 1999). Immigrants provide more than half of the formal direct care for frail elderly residents in New York City. It is easier for them to find work in direct care than in other fields. The nature of the work is more familiar to many immigrants than other kinds of employment, and the low wages make such jobs easier to get than higher-paying jobs. Home health aides and personal care assistants from Nigeria, Haiti, Ghana, and India tend to cluster together in individual facilities. One cannot begin to understand the system of long-term care in New York or that...

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