Reinventing Care: Assisted Living in New York City

2. A Brief History of Care

28 2 A Brief History of Care To Europe she was America, to America she was the gateway of the earth. But to tell the story of New York would be to write the social history of the world. —H. G. Wells, The War in the Air This chapter presents the history and the alternative paths that have been chosen in the past in caring for the frail elderly in New York City. This sector of the population needs assistance with the same activities of daily living (e.g., ambulation, feeding, dressing, bathing, etc.) now as they always have. Understanding how this care has been provided in the past makes the present-day conflicts more predictable. In telling the story of the social history of care for the frail elderly in New York City, or anywhere else, it helps to break it down into two separate stories, one about the predictable recurring tensions in how such care is organized and one about the more recent and less predictable disruptions that have profoundly changed the nature of that care. The Recurring Themes In part, the story about care for the frail elderly is one that involves three recurring conflicts over the nature of that care, conflicts over its purpose , its organization, and the role of government. Purpose Well into the twentieth century, public debate about how to care for the frail elderly was submerged in the debate about of how to deal with the poor. There was little that medicine could offer that could make any difference , and families informally provided most of the day-to-day care that was needed. The frail elderly represented only a tiny fraction of the A Brief History of Care 29 population. In 1900 only one tenth of 1% of the population of the United States was over the age of eighty-five. In 2000 the proportion of the population over eighty-five had grown more than sixteenfold to 1.6% and was projected to reach 4.6%, or almost twenty million, by 2050 (Federal Interagency Forum on Aging-Related Statistics 2000, 56). The poor, however , of which the frail elderly represented only a small fraction, have always been a concern. The debate over how to handle the indigent has hinged on how much government should focus on attempting to eliminate , or at least ameliorate, the problems of poverty and how much just on controlling it. The prevailing position in New York City, as elsewhere in the United States, has been that attempts to alleviate poverty might well attract an even greater concentration of poor, and so efforts should focus on control. Throughout the city’s four-hundred-year history, the fear that beggars, petty thieves, the homeless, and unruly mobs would inundate the city focused concern on policing the poor. Those fears helped shape care for the frail elderly. Organization A second related conflict involved whether to organize such care around “outdoor” or “indoor” relief. Indoor relief means providing care in an institution , an approach that is based on the assumption that residents and their care can be better controlled in such a setting. Outdoor relief means either providing financial support so that recipients can purchase what they need for themselves or directly providing food, fuel, and personal assistance in the recipients’ own homes. These differing approaches raise the question, Should care be institutionalized or deinstitutionalized? How this question is answered reflects the perceived purpose of such care and the relationship between those providing the services and those receiving it. If those who are to receive care are considered dangerous or destructive to themselves or to the social fabric of a community, then it is likely that the community will choose to provide care through indoor relief. If the recipients of such care are seen as being like other members of communities, then the balance shifts toward the more sympathetic, more attractive, and less stigmatized treatment provided by outdoor relief (Lowell et al. 1900). The conflict over indoor as opposed to outdoor relief, however, has also been a conflict over which costs less. The advantage of indoor relief is that the number of people receiving care through institutions can be restricted, and thus costs can be controlled. However, per recipient, 30 Reinventing Care outdoor relief is far cheaper. For example, in Massachusetts in 1889, the average cost of keeping a pauper in an almshouse was $180 per year, but the average cost...