DR. VERONICA DOYLE, PH.D.
Manager, Housing Policy
Ministry of Social Development and Economic Security
Victoria, British Columbia

NOVEMBER 18, 1999

When considering the whole topic of supportive communities, I believe it is important to think very broadly. It is very easy to think in terms of services and programs that need to be available for any particular group of citizens. However, a supportive community is not one that simply provides services and programs. A truly supportive community is one in which everyone can participate with dignity and respect, one in which neither the physical nor the social environment creates barriers. Since this forum is directed primarily to issues that affect an aging population, I will focus my remarks on this topic, but I want to reiterate that communities need to be supportive for everyone. Older people need to be seen as having a valued role but they also have an obligation to contribute for the benefit of other segments of the community, as they frequently do.

1. A supportive community depends on acceptance of each other.

The first thing we must do is dispel myths about population aging that arise from non-scientific and in fact "ageist" assumptions. Although demographics is an important science gaining rapid respect, we must realize that we cannot predict future behaviour based on numbers, nor do we have a full understanding of the factors that will affect the future.

Remember the predictions about:

• the vast amounts of leisure we were going to have,
• the isolation that would result from widespread use of computers, or, for that matter
• the prediction that everyone would want to work from home?

Even concerns about overpopulation of the planet are changing as we realize that once economic circumstances improve in developing countries, and particularly once women begin to become educated, birthrates tend to fall.

Things will indeed change, but it is not fundamental to the idea of an aging society that they will change for the worse. As the population ages, social problems and expenditures that are mostly associated with younger groups tend to decrease. For example, we are now seeing falling rates of crime, particularly violent crime, reduced expenditures on motor vehicle accidents associated with reckless speed, and lower relative expenditures on schools.

 Although the numbers part of demographics can be fairly exact, neither the assumptions and interpretations underlying those numbers, nor the conclusions are nearly so firm. I would like to raise two examples that illustrate the caution with which statements about population aging should be considered, and I raise them because when widely believed, those statements can lead to – or appear to confirm – decisions that make communities very unsupportive.

Example One: Stating the percentage of a population over 65 can be used to mislead if not presented in context.

The population of Canada aged 65 and over was 12.3% of the total population in 1998 and is projected to be 15.9% in 2016. The corresponding percentages for Alberta (1996 and 2016) are 9.8% and 14%. (Canada as a whole last had a 65+ population like Alberta’s today in 1981 when nobody was worrying about the impact of an aging population). The population of British Columbia, on the other hand, was 13.1% seniors in 1996 and is projected to be 16.3% in 2016.

If we read only the popular press, we would conclude that this high percentage of seniors is a problem – an aging population will bring us a stagnant economy, high levels of poverty, distinctly un-vital communities and many demands on the pension and health-care systems. However, we should consider some comparison statistics. Victoria BC in 1996, a beautiful and interesting town with a vital economy, high levels of employment and low levels of poverty, had 18.1% of its citizens over the age of 65. In the middle of this decade 17.4% of Swedes, 16.6% of Italians, 15.7% of Britons, 15.4% of Germans, 15.2% of Swiss and 14.5% of Japanese and citizens were seniors.

I am not arguing that things will not change and do not need to be planned for. Rather, I am pointing out that the stereotypes of an aging society are not borne out when one considers cities and countries that are already there.

There is indeed a concern with respect to the very elderly population if they remain the same as today’s population of the same age. At the moment, the population 85+ is increasing rapidly because they represent the baby boom from high immigration levels early in the century, the parents of the small generation born during the Depression. This is one reason why there is a growing sense of urgency in most towns and cities about supportive housing and care beds.

Table 1: Population 65+ and 85+ Canada, by Province 1998

At this point, people 85+ represent 1.3% of the Canadian population, projected to be 4% in 2041; but there will be a leveling-off in between as the small ‘30s generation moves through. The post World War II baby boomers will not begin to reach 85 until 2030, peaking in 2044. The numbers are now and will remain relatively small. This gives us time to plan for healthy and supportive communities in the future.

Example Two: Interpretation of statistics is sometimes questionable.

Table 2: Dependency Ratios, British Columbia, 1921 – 1996

Table 2 shows dependency ratios over the years. The dependency ratio is the number of persons in the age bracket less than 15 (the youth dependency ratio) and 65+ (the seniors dependency ratio) per 100 persons aged 15 – 64. Together these two statistics make up the overall dependency ratio.

The first problem with dependency ratios is an outdated definition. In 1921, the life expectancy at birth was 59.7 years and there was no old age pension. An income-tested old age pension of $20 per month was introduced in 1927 for people aged 70 and over. At that time, elderly people, if they did reach the age of 65, were very likely to be dependent. To consider anyone aged 65 and over today as by definition dependent is, to say the least, problematic. On the other hand, those aged 14 or less are still completely without resources and dependent on their parents and society as a whole.

The second problem with linking dependency ratios to an assumption that an aging society is in itself a problem can be seen by looking at the table. Dependency ratios in 1996 were (and had been for fifteen years) about the same as those in 1921. In between they were much higher – 47% higher, in fact, in 1961. This is largely because of the very high youth dependency ratio during the baby boom. The seniors’ dependency ratio has been in the 17 to 19% range since 1951. The youth dependency ratio will likely continue to fall over the next 20 years (failing a new baby boom triggered by anticipated labour shortages and increasing wages) as the seniors’ ratio rises.

In actual fact, seniors, far from being dependent, are a relatively well off group who make a considerable contribution so Canadian society, as the following information shows:

• The portion of seniors with low incomes has fallen. Percentage of seniors in Canada with low incomes (LICO 1992 base) fell between 1980 and 1997 as follows:

• for men, from 26.6% to 11.7%
• for women, from 39.8% to 24%
• in total from 34% to 18.7%.

This decrease in low income levels, welcome as it is, is somewhat artificial, reflecting as it does increasing access to the Canada/Quebec Pension Plan beginning in 1969, especially for women. We still have 22% of seniors who never worked outside the home and their incomes have not risen in concert with the averages.

Current (1997) levels of poverty are: Alberta 13.6%; British Columbia 19.5%; Saskatchewan 13.4%; Manitoba 22.6%.

• Seniors pay taxes. While families with head under 65 pay about 22.1% of income (1997 data), seniors-headed families still pay 17.7%. Even unattached senior women paid 10.6% of their income in taxes in 1997. The average unattached woman 65 and over, who had an income of $18,399 (Canada; $19,147 in Alberta) in 1997, pays an income tax in the range of $2,000 per year as well as all other sales and likely property taxes. Seniors with higher incomes also repay the basic Old Age Security.

• Seniors give to families and communities. While Canadians under 65 spend 1.7% of income on gifts and contributions, senior-headed families spend 5.9%, and unattached seniors, who as a group have very low incomes, 8.9%. In addition, 23% of seniors do formal volunteer work and 58% do informal volunteer work.

• Seniors live independently and take care of themselves (and each other). Ninety-three per cent of elderly Canadians live in the community, with family (69.4%) or alone or with non-relatives (30.5%). In Alberta it is 92.2%, with 20,675 living in institutions, in BC 95%. Seniors devote the same amounts of time to household chores each week as younger people. Seven per cent of them spend more than 5 hours/week (half of those spend more than 15 hours/week) just helping other seniors – besides considerable childcare and other family/community contributions.

Summary: The first component of a supportive community is respect and recognition of each other’s contribution to the community overall. Once we have recognized that popular stereotypes of the burden of an aging are very questionable, I believe we should move on to acknowledge the particular circumstances and concerns of all groups in society and work on the community’s capacity to address them.

A particular case in point is the relative need of senior-headed families and those led by single-parents: While 6.8% of the former lived under the low-income cutoffs in 1997, 23.5% of male-headed single-parent families and 56% of female-headed ones were poor in that year. We particularly should focus our collective efforts on the poverty of children, now that we have improved the incomes of seniors to such a great degree.

2. Supportive Communities are Healthy Communities

Part of the doomsday scenario about population aging is that all these older people will swamp the health-care system. However, that scenario is based on the assumptions that:

• seniors will be the same 20 years from now as they are today, i.e., that tomorrow’s 85 year old will be as sick as today’s 85-year old, and
• the way seniors are treated in the health-care system is the correct way to treat them.

With regard to the first assumption, it is of course impossible to know whether tomorrow’s very old people will be as sick as today’s. We can, however, look at whether today’s old people are as sick as those of the same age two decades ago. While Canadian data are limited, the balance of research in other countries suggests that they are not. US studies show that age-adjusted disability levels are falling. One projection in 1982 predicted that the number of disabled elderly in the US would rise from 6.4 million to 8.3 million by 1994. The actual 1994 number of disabled seniors turned out to be 7.1 million. The forecast based on the 1982 level of disabilities was too high by 63%. While we cannot assume that the trend to improving health (and for that matter increasing longevity) will continue, we can hope so.

With regard to the second assumption there is little question that the health system in Canada is treating seniors much more intensively than in the past. Many health care providers are aware of increasing numbers of seniors in their practice. There are a number of factors underlying this phenomenon, of which I will mention only a couple, and very little of it has to do with the aging of the population as such. Whether we are treating seniors in the best or correct way is another question.

Research in BC databases has shown that population aging has accounted for very little (less than 1%) of the increase in health care costs over the last three decades. Rather:

... the health care system is doing much more to (and for) seniors than was the case even a decade ago. This suggests that the appropriate care of elderly people should be a central issue for health care policy and management, but that demographic issues are, in the short run at least, largely a red herring.

Studies suggest that the increasingly intensive servicing of the elderly is to some degree inappropriate or at least unproven. One factor is simply commercial and entrepreneurial: there are new drugs and new treatments being developed all the time, and there are more doctors entering the system – at least in urban areas. Health care is an industry that, like any other industry, is organized to grow.

In addition, we are increasingly using a system of acute care hospitals designed for episodic illness of otherwise healthy people for the "non-specific and chronic" diseases that are more typical of elderly people. Hospitals are also taking the place of housing to a considerable degree. Old people who in the past would have lived with family are now living in long-term care facilities, and/or living in acute-care hospitals waiting for a "bed" in such a facility. Likewise, people are living in long-term care who could be supported in the community if only a safe, affordable and appropriate place to live could be found.

 In this sense the "continuum of care" applies in both directions. While we typically think of old people as likely to need increasing levels of care – to the point that the concept of continuum of care can be a self-fulfilling prophecy – in fact elderly people are like everyone else: they have an accident or become ill, and usually get better again. Many could move gradually back into the community after an illness or a fall if the right kind of transition and housing were only available.

In particular, we should be making better provision for recovery from a fall. Falls have been shown to be the most frequent cause of injury-related hospitalization and death among seniors. The cost of falls for seniors in 1994/95 (Canada) was $2.8 billion: $2.3 billion for hospitals, most of the rest for physicians.

A third factor in maintaining a healthy community that applies in particular to older people is integrating a social model into the predominant medical model of health.

Table 3: Promoting Health -- Three Complementary Approaches

Keeping a community and its citizens healthy is a combination of all these approaches. While a person’s genes and a person’s cumulative life-style decisions both contribute to individual health, several decades of research show that the primary determinants of health are social, and this is where supportive communities comes in.

Chart: Death Rates by Socioeconomic Indicators, BC 1995

The strongest determinant of a healthy community is socioeconomic status. Low status is in itself pathological; high status appears to give a biological resistance to disease. This chart shows death rates in British Columbia’s health regions for the whole population and for children, graphed against an index of three socioeconomic variables: percentage of the population receiving social assistance, percentage aged 25 – 34 with less than high school graduation, and unemployment rates. The relationship between high scoring on the socioeconomic indicator and low death rates can clearly be seen.

Research shows that high status is important not because of improved lifestyle but because it connects us to the community and gives us access to social networks that make us "somebody." The biological pathways for this effect are now being researched, but the effect itself is pretty well indisputable.

When we talk about a "social model of health" we are talking not about intimacy, having friends, having someone to help out in an emergency, though these are all undoubtedly important to individual wellbeing. Rather we are talking about our place in society, our continuing participation, the opportunity to make decisions about our lives and circumstances.

 A person who enters a hospital or care facility, for example, loses control over even the most basic aspects of life: when and what to eat, when to sleep and wake up. To speak sociologically for a moment, they take on the degraded role of "patient", on top of the already "low-status" roles they may have of "old person", "poor person" and/or "woman" rather than remaining an independent and self-maintaining citizen. There are times when a person is sick or tired enough that the comfort of being taken care of is all that is wanted, but if that is not the case, an environment that allows a "respected social role" will be more health-promoting.

It follows, then, that supportive communities does not mean primarily provision of programs and services, but the right to participate in the community on an equal basis, the right not to be excluded or marginalized.

Housing is a key factor in a supportive community.

Housing is an example of how the "supportive community" concept can be put into practice, if you consider housing through the lens of the social model of health. Housing is a mid-level variable where the effects of social structures can be mitigated. Housing can also assist on the biomedical and lifestyle levels.

We know that older people, particularly older women, prefer to remain living independently in the community. In fact, older women overwhelmingly prefer to live alone, citing their desire for privacy and independence, the ability to do "what I want to do, when I want to do it." This generation of older women appear to value the opportunity to live as they wish without having to be responsible for taking care of other people. Research I have done with older women on this subject was so clear on this point that there was no other possible title for the report than It’s My Turn Now.

However, if health and energy begin to decline, it is more difficult to maintain an independent lifestyle, particularly to stay socially connected. At this point, the first thing we should do is look at the person’s environment, and focus on:

• Minimizing environmental demands and risks
• Providing social opportunities, and then
• making specific services available as needed.

This is not to minimize the importance of clinical interventions, but to state that in the long run and for most people, the individual’s place in the community will be the most important determinant of their health.

There are many ways of making environments more enabling for individuals in the community. One of these is to combine a housing environment that minimizes demands, with opportunities to maintain a social life, and access to services. This can be in purpose-built supportive housing, a naturally-occurring retirement community, conversions of older buildings or regular housing strategically placed near amenities.

It is useful to think about supportive housing in a much older context: what supportive housing tries to do is recreate the traditional village – a place where demands are reduced and the necessities of physical and social life are easily accessible preferably on foot. Someone who already lives in a village doesn’t need to go out and find supportive housing. They may, though, need help or funding to make the dwelling itself more usable and safe. The CMHC Housing Assistance for Seniors Independence (HASI) provides a good model, though some argue that its $2,500 limit is not enough. Another service that would help people to remain in the village – that many home owners can pay for – is reliable help with yard and building maintenance.

Those of us who do not live in a village, who live in suburbs or rural areas, may need to find it more purposefully developed. In BC the housing ministry and the ministry of health/responsible for seniors have just completed a year-long consultation on supportive housing. Realizing that many communities, large and small, were ready to mobilize to provide the type of housing they believed would be useful locally, we developed a very descriptive definition that is more a listing of criteria than prescription of a particular model:

Supportive housing combines building features and personal services to enable people to remain living in the community as long as they are able and choose to do so.

Supportive housing is first and foremost housing, with a combination of services, including at a minimum:

• A private living space with a lockable door
• A safe and barrier-free environment
• Monitoring and emergency response
• At least one meal a day available, and
• Housekeeping, laundry and recreational opportunities.

Nursing and other health-related services are delivered by the local health authority through special arrangements or as they would be to any other individuals living independently in the community.

Supportive housing, in our view, is a supportive, but not a health-care environment. It is different from assisted living, where care services are offered on site, usually on an as-needed, flexible basis. Assisted living is a form of care that takes place in a housing setting. There are many other new approaches to care that try to be more homelike, and often these are very effective, but it is important to distinguish between housing and housing models of care. This is important because of the social model of health: if a person lives in housing, she is an independent, or at least semi-independent member of the community. If she lives in "care" that role is much more difficult to sustain. To reiterate: the purpose of supportive housing is to help individuals maintain independence, not to provide care.

Seniors might choose supportive housing for many reasons beyond an immediate health or support need. For instance, they may want to ensure that if and when their health fails, they are well set up to maintain their independence.

Supportive housing developments are becoming more available and demand can only be expected to increase. In particular, there will likely be more demand for a variety of supportive housing options as generations that are used to more choice in their lives reach the age of needing more support.

Key policy issues that need to be addressed with regard to supportive housing are:

• Affordability. Supportive housing provided by the private sector is priced well beyond the amount that most older low-income and even middle-income people can pay. Home owners can convert their equity and I am aware of many local initiatives in British Columbia to provide supportive housing on a non-profit basis, through life leases, for example. This approach combines the individual’s equity, at-cost operating expenses, and often free or discounted land contributed by local government or health authority or an older social housing development. In this way the costs can often be reduced to a level that is reasonable for home owners.

For renters, the cost of supportive housing is generally out of reach. The government of BC, which still maintains a small social housing program, has recognized this fact by allocating up to 400 units over the next two years for supportive housing for seniors. The literature suggests that this will likely prove cost-effective over the long run through preventing at-risk individuals from ending up in care facilities.

• Consumer protection. In British Columbia, the statutes that regulate the relationship between tenants and landlords, and between the buyers and sellers of real estate, recognize residents as consumers making a housing choice using the resources available to them. Persons who live in care facilities, on the other hand, are deemed to be in need of protection. Licensing laws and regulations exist to specify with some exactitude the design, staffing and provision of services in such facilities. Neither of these regulatory systems applies very comfortably to the in-between situation of supportive housing which offers a specific type of shelter and generally includes a commitment to make services available on a package or as-needed basis.

Our review has recommended that BC approach this issue as a consumer protection issue rather than apply a licensing model to supportive housing developments. A consultation to develop such a system will begin this winter. Options that we are considering range from a voluntary system of standards and guidelines through to new legislation that would apply specifically to supportive housing. One issue we particularly have to address is the hybrid tenure form of the life lease in which a large sum of money is paid in advance. While these fees are protected before occupancy in British Columbia, it is essential to ensure that the operator uses those funds for their intended purpose and makes provision for their return at the termination of the lease.

• Linkages with health care system. The health care system is not generally designed to take an individual’s environment into account, or to recognize the option of supportive housing. For example, while most communities have home care available, although to a diminishing degree, there has been in BC a limited recognition that those services could be more effectively delivered in a supportive housing setting. Thus, even in supportive housing, a dozen home-support workers may be arriving and departing daily, when one person could be paid for on-site services.

It is important to ensure that individuals who are no longer well enough to live on their own even in supportive housing are moved to a care facility as soon as possible. It may be tempting for harassed health-care workers to leave people in what is, after all, a relatively protected setting, giving priority for limited care beds to individuals who appear to be more at risk. However, beyond the obvious effect on the wellbeing of individuals, it is critical that as residents age in place, the supportive housing developments not become simply cheap – and unlicensed – care facilities. A wing or nearby building licenced for care is a good solution to this problem.

• Aging in place. The principle of aging in place means that seniors should be able to stay in their preferred living environments for as long as possible. This principle must be kept in mind when an older person is considering a move to supportive housing and what to do if his or her health fails while living there. Adjusting services to changing needs would be more helpful than requiring a person to move to a new setting, i.e., a care facility, to receive those same services. Moving demands changes in lifestyle and disturbs links with the larger community, changes that can seriously affect how individuals feel about themselves and reduce their sense of wellbeing.

However, if seniors are to age in place, all the necessary support services must be available. Each supportive housing operator will have to decide what type of supports to offer, and whether and how they should require residents to leave if their needs go permanently beyond those that can be met in their particular setting. Some providers may aim to maintain an environment that is primarily housing, by establishing a clear requirement that a person must move if care needs increase beyond a certain point. Others may choose to support residents to a much greater degree. In either case, the consumer is entitled to a contract that clearly specifies the provider’s exit policy. "Campus" models that have housing in conjunction with a care facility or hospital are a good solution to the issues raised by the concept of aging in place.

4. Supportive Communities for the Future

Since supportive housing reflects a social model of health, it follows that supportive housing – however achieved – must be embedded in a supportive community. Other important components of a supportive community are:

• Built environment and infrastructure.

• The pedestrian environment. Sidewalks, streets, steps, lighting, crosswalks must be planned for safety and ease of movement. There is a role here as well for preventive exercise programs that address individuals’ stability, strength, and balance, and encourage the use of proper footwear.

• Planning and design. Many of our communities are planned for the almost exclusive use of families living in single-detached dwellings and possessing one or more automobiles. Most of the City of Vancouver, for instance, was zoned single-family (floor space of the dwelling no more than .6 the size of the site) in 1929, and any change in that density is achieved on a site-by-site basis, frequently with considerable local acrimony. This makes it very difficult to develop apartment buildings that would allow seniors to live in a house that makes fewer demands while remaining in their own communities.

Likewise, secondary suites are a valuable option for older home owners who would like to trade excess space in their homes for more income, or simply the comfort and safety of having others nearby. In other cases, families like to have a suite for an older relative, which allows "intimacy at a distance." However, many are uncomfortable doing something many consider "illegal" and worry about possible complaints by neighbours.

Building codes and design guidelines should also be reviewed for safety and accessibility, with a stern eye out for standards that are unnecessarily high and add costs without substantially improving safety or mobility.

• Transportation is critical and may become more so as the number of seniors in the suburbs and rural areas increases.

Some of the issues involved have to do with the still-limited proportion of older women who possess drivers’ licences. Those who do not must depend on friends and neighbors or on public transportation systems designed primarily to serve people commuting to work. Others revolve around safe driving conditions for older drivers: size and location of street signs and traffic lights, street lighting for night driving to minimize glare, width of lanes and parking lot spaces to accommodate larger cars often preferred by older drivers. A third set of considerations is the continuing effort to make public transportation itself more accessible, convenient and safe.

• Businesses and services are becoming increasingly accessible and user-friendly, but there is a lot more education to be done – education that will no doubt follow the rising recognition of the size of the seniors’ market. Public amenities such as libraries, theatres and sports facilities will also have to look at this ever-increasing segment of their audience. In particular, the next generation of seniors can be expected to be considerably more demanding than the current one. As always, the "boomers" will have clear ideas about what they want. They will not be confined to a few favourite pastimes and many, particularly the women, will not be limited by the prevailing low income of their mothers.

• Partnerships. Funding limitations, while sometimes exaggerated in catastrophic predictions about the "grey wave" descending upon us, are real. The resources we have must be spread across the needs of all citizens. Therefore, we need to bring as many partners as possible into the process. In doing so, we will likely find that a partnered solution often works better, reflecting as it does the commitment and support available in the community.

For example, our housing program in BC gives priority to social housing applications that bring community support and community equity with them. In many cases the local government or a non-profit society can provide land; the council sometimes waives fees and charges or makes grants in lieu of taxes. In one supportive housing development opened this summer in the Slocan Valley, every stick of wood was donated, down to the locally-designed ergonomic chairs in the lounge.

This approach of using public funds to leverage community and private-sector donations has stretched British Columbia’s limited social housing budget much farther than expected. For instance, in 1998-99, the original allocation of subsidy funds to cover 600 units actually produced well over 800 units for low and moderate income households.

Another valuable source of partnerships is between housing and health. The Vancouver/Richmond Health Board now has a director of housing, who works with BC Housing and the City’s Housing Centre to develop housing in areas such as the Downtown East Side. For example, non-profit societies have been funded to purchase old single-room occupancy hotels. These then provide decent and stable housing with enhanced management such as 24-hour staffing for individuals with mental or physical conditions that put them at risk of homelessness. The health board has also noted that funds it allocates for leasing or purchasing program space can serve a double function if used to reduce costs for housing on upper floors of the same building.

Such partnerships have produced more than 1,000 social housing units for various groups in the City of Vancouver over the last several years.

• Provincial policies should be oriented to developing community and individual capacity to identify and remedy problems: leveraging community resources, funding pilot projects, community grants programs, education and advocacy. In particular the not-for profit, co-op and volunteer sectors have an important role to play not only in providing services but also in raising community awareness and willingness to address issues. Sometimes government has to kick-start and support this basic democratic process.

• Opportunities for participation and integration in community life. Obviously, a supportive community is one in which older people have a real role in the community as long as they wish it. However, in closing I would like to stress again that older people have a corresponding obligation to accept and support the young: civility works both ways. While I find myself bristling at suggestions that sickly seniors are going to absorb all available resources in the future, I think it is equally problematic to hear people demanding special consideration because "I paid taxes all my life" or declining to support local schools and family housing.

To summarize, I believe that on balance most of us have done well and are doing well in Canadian society, and that most of us will do relatively well in the future. A supportive community is one in which those who are doing well recognize an obligation to assist those who are not, and do so in a respectful and empowering way that creates a truly healthy society.