“Perhaps the worst will happen, perhaps not, but until then look forward to better things.”

— Seneca the Younger

As a young psychiatrist in the United States, I had a special interest in meeting and treating older people. Two memories of older patients stand out from my training in Houston and then later, while I was working in rural Arkansas. As a young trainee psychiatrist, I was called to see a man in his nineties brought in from a local nursing home in Houston. Like most elderly in the US, once he was unable to care for himself at home, he was placed in a nursing home where he continued to slowly decline physically and mentally. By the time he was brought to us in the hospital, he was barely human: unable to walk or talk, lying in bed in a fetal position, in and out of consciousness. But he had developed a high fever and the nursing home had sent him to us. Even then, as a novice, I was both fascinated and horrified at what advanced old age could bring.

Another patient, a woman I cared for in Arkansas for a while, was not quite as bad off but still quite old and bed bound. She could talk which meant that at least I could hear her out and try to help as best as I could. She would lie in her nursing home bed surrounded by photos of her children, grandchildren and great-grandchildren and look out the window all day. She missed them and wished that they would visit more often but they were busy with their own lives and even the ones who lived in the same town could only manage to visit once or twice a month.

Fast forward twenty years and my wife and I are now caring for several elders in our own family in Lahore, while in my practice I have dozens of families struggling with the same issues that I saw in the US. While our extended family system offers some protection against the worst of the isolation and loneliness which elders experience in the US, the economics of our country dictate that children in every family – sometimes all of them – have to go abroad to work to support the family members back home.

On December 14, 1990, the United Nations General Assembly designated October 1 as the International Day of Older Persons. As we mark the day this year, we should reflect on where Pakistan stands.

Our population pyramid, a visual representation of a country’s demographic makeup, is still upright, meaning we have a very large population of young people and a very small percentage of people over the age of 60. This can be attributed to our very high birth rates (declining very slowly). While we all bemoan our unchecked population growth for various reasons, having a large young population means all kinds of growth and economic possibilities for a nation. This can be contrasted with a country like Japan whose population pyramid is completely upside down – meaning a huge number of very old people (who cannot work and who have substantial medical and social needs), and a very small and declining number of young people who can work and contribute to the economy.

While an extended family system offers some protection against the worst of the isolation and loneliness which elders experience in the US, the economics of our country dictate that children in every family — sometimes all of them — have to go abroad to work to support the family members back home. 

In spite of our young population, the proportion of the elderly in Pakistan is growing rapidly with average life expectancy having grown to 69 years and still rising due to various factors including better healthcare.

Being able to grow old (and hopefully, wise) is a blessing. Those of us on the cusp of it are truly grateful for it. Unlike in Western societies, being surrounded by close family is also a magical experience which everyone living abroad longs for. But old age brings its own challenges including emotional ones. As the body ages, so does the brain. Emotions, too, become fragile. As one grows older, losses begin to mount: elders become sick and pass away, old friends likewise. Children growing up in Pakistan strain to break the chains of the parent’s home and fly away to experience the ‘magical’ world of the West as they imagine it (leave aside the fact that their fantasy is just that, a fantasy). Many choose to study and then live and work abroad to support families back home. Over the last several years, I have treated dozens of elders and families, all of whose children are abroad while the elders live alone – lonely and, sometimes, depressed.

Can something be done?

Clearly, the hard logic of economics cannot be overcome by wishful thinking. The career and income opportunities of the West cannot be replicated in Pakistan anytime soon. However, things have already changed for the better compared to when I was living full time in the US. Advancements in communication mean you can see and talk to family on the phone or on a screen as many times a day as you want. Flying to Pakistan is an annual ritual for most expatriates and, of course, everyone sends money back home to help. Here in Pakistan, social isolation and loneliness are mitigated by multiple factors: visits to relatives or friends nearby, extended sessions with friends, old and new at the local park; yoga, gym and ‘Islamic’ classes for women that happen both at home and in public spaces. And, of course, our culture’s great emphasis on respecting and valuing the elderly as sources of wisdom, knowledge and love – something we share with all Eastern cultures. Research has shown time and again that the one single factor which is protective against all kinds of illnesses, physical and emotional, is connection – to other people, to community and to society at large. While industrialisation gradually degrades that connection, here in Pakistan at our stage of economic development, we still have enough of it – even in our mega-cities – for it to make a difference.

As our nation continues to evolve, we should keep that in mind and make every effort to preserve our connection to one another and to our elders for our own sake and for our future generations.

The writer is a psychiatrist and faculty member at King Edward Medical University. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022. His X handle: @Ali_Madeeh