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Cross-National Perspectives on Environments for the Aged Sven Thiberg As a foreign "reporter" in the area of environments for the aged, ~ have, with some difficulty, defined my task in this paper as one of providing a cross-national perspective by discussing phenomena that ~ consider to be characteristic of the Swedish situation regarding "the aging society." ~ have chosen to begin my paper with a brief summary of what T consider to be the extrascientific or social goals of Swedish aging policy within the social and built environment sectors and the research policy goals or tasks that follow from them. ~ base this summary on extensive material from reports by government commissions, research reports, and political documents. It would be going too far to maintain that there is consensus concerning the points ~ raise. Yet T consider that they reflect broad opinions and to a large extent can be stated to form a basis for practical action within the sectors concerned. The advantage of my model is that it can be used as a struc- ture for analyses both of actual conditions and changing trends and of research and research needs. In this context, ~ see one important research task being the evaluation of social goals: checking to ensure that government policy and programs have been set up to comply with what citizens see as necessary and Sven Thiberg is with the Royal Institute of Technology, Stockholm, Sweden. 190
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 191 that society is able to meet their desires to a reasonable extent. In addition, researchers must clarify a number of quantitative and qualitative assumptions regarding aging and the society in which we grow old. The social and built environment constitutes a kind of intermediate link in this broad spectrum of phenom- ena, whose breadth does not exactly simplify our task or render the limitations of our subject field particularly self-evident. In attempting a cross-national overview, the differences be- tween the American and the Swedish views of society must be addressed early on. The American society is characterized by a greater pluralism. It is expected that different alternatives will emerge spontaneously and that the market mechanisms will function in such a way that satisfactory solutions successively crystallize. Swedish society is more homogeneous, and the wel- fare of all is a prominent societal goal to be attained through universal measures. National and local governments, therefore, also undertake the responsibility for development and change. The great material and social gaps that exist in the United States among population groups would be unacceptable in Sweden. It is difficult to say exactly what sacrifices Swedish citizens make to achieve the material standard offered by our system of security based on taxes, pensions, allowances, and financing measures. The differences in the U.S. and Swedish social systems are particularly distinct when it comes to the elderly, who in neither country can any longer base their social and economic security on their own work or on relatives but are dependent on different types of welfare. How these welfare sys- tems are constructed, who they cover, and who stands outside them are fundamental factors that also affect the design of the social and built environment. IS THERE A GLOBAL PATTERN? The changes in the age pyramid in all industrialized countries are characterized by a falling birth rate and growing longevity. Urbanization and industrialization often level out cultural and societal differences and lead to increasingly uniform life patterns. An element in these life patterns is the separation of the generations as their economic dependence on one another dimin- ishes. Improved health and a growing material standard enable
192 SVEN THIBERG the elderly to live an independent life. Only the very oldest are dependent on intensive care. This trend has reached varying proportions and differs in its dramatic qualities in different countries. Sweden is an extreme case in terms of the economic independence of elderly persons and public responsibility for their care. Other countries base their policy toward the aging largely on assistance from rela- tives and on the elderly living together. Yet to provide an answer to the question, "Is there a global pattern?", one must make assessments ranging over three fields. First, one must describe the present situation of the elderly. Depending on the resources and economy of different societies, the availability of data on this issue varies enormously. As is true of the United States and most industrialized countries, Sweden possesses abundant data about the demographic struc- ture of the elderly population as well as about medical, social, and material conditions. The production of data in the develop- ing countries is limited, and it is difficult to make statistically satisfactory comparisons. Yet the data suffice to confirm the great differences in living conditions in general terms between different countries and within different countries. Second, one must describe the goals that exist for the lives of elderly persons in society across nations, a question that be- comes immediately more difficult and of greater interest. Cul- tural differences appear that cannot be explained by simply coupling them to the degree of development in a country or to its material standard of living. A good example of this phenom- enon involves Japan and Sweden. The differences between these two countries in material standard of living, education, and system of production are far less than the differences in cultural views and social valuations of the forms of life of the elderly. It is not merely that 7 percent of the elderly in Sweden and 60 percent in Japan live with relatives. The declared social goals of the two nations differ just as much. In Sweden, the national policy is that an independent life is desirable and that it can only be attained if older people live in their own homes; in Japan, the state advocates that the elderly shall live with their relatives. Great efforts are made in Sweden to support old peo- ple living on their own; in Japan, no reason is seen to develop such support because it is considered to conflict with the desir- able social pattern.
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 193 Third, one must describe the factual changes in the respective countries and find explanations for them. Thus, although the Japanese policy toward the elderly may show the contrary (i.e., no change) or at all events a great inertia in the pattern of change, everything indicates that a growing degree of industri- aTization leads to increased mobility, the splitting up of house- holds, and less stable families. In the Tong run, the trends have the effect of separating the young and the old even more than they are at present, and in general, cultural ties do not appear to be strong enough to prevent this development. This split, in turn, has necessitated changes in the financial maintenance systems of many nations and has given the elderly an economy that is even more independent of the young. In the Western nations, we have become accustomed to speak of generation gaps. That such divisions exist is manifest. But it is not correct for that reason to draw the conclusion that eco- nomic independence creates such gaps. Recent Swedish studies show the contrary: that economic independence for both parties can lead to relations on equal conditions and with mutual social exchange. THE SWEDISH EXPERIENCE In 1984 a Swedish government commission summarized the housing conditions of the nation's elderly as follows. The great majority (90 percent) of the Swedish population over 65 years of age live a normal life in ordinary housing. Of those citizens older than 75, 80 percent live in their own flat or house. Even in the group aged 85 and older, more than half live in an ordinary dwelling. Of the old-age pensioners, 2-3 percent live in a service block, pensioners' home, or the like; 7 percent live in institutions, 4 percent of which are old-age homes. Nearly 90 percent of the elderly who live in ordinary housing have fully modern flats. Despite a rapid improvement in stan- dards during the 1970s, however, the pensioners' housing stan- dard is still inferior to that of the remainder of the population. Nearly half (43 percent) of the nonmodern housing stock is oc- cupied by old-age pensioners. Every tenth pensioner lives in a nonmodern flat, every fifth pensioner in sparsely populated areas. Of the households of elderly persons there are 42S,999 in Sweden 43 percent are in small houses and have a lower
194 SVEN TNIBERG average standard of equipment than those in blocks of flats. Many of the semimodern and nonmodern flats are pensioners' dwellings and pensioners' homes. Some 135,000 elderly persons (29 percent) who live alone live in one room and a kitchen; that is, they lack a separate bedroom. Of households of two or more persons some 23,000 are in flats of at most one room and a kitchen, which for Sweden, constitutes a very Tow space standard. Many of these households are pen- sioners' dwellings or pensioners' homes. According to the 1975 pensioners study, 40 percent of old-age pensioners who were not living in hospitals, nursing homes, and old-age homes were living on their own; broken down by sex, 20 percent of elderly men and 50 percent of elderly women were living on their own. The differences between the sexes may be explained by differences in length of life, differences in the ages of husband and wife at marriage, and differences in sex roles having to do with the availability of other people and the ability to Took after a household by oneself. More elderly people in Sweden now live on their own, both in absolute and relative terms. Today 47 percent (around 470,000) of all pensioner households consist of people living on their own. It is more common to find elderly persons living in blocks of flats than in small houses. There is also an increase in the number of people living on their own with age: 28 percent in the group aged 65-69 years compared with 56 percent in the group 85 years and older. According to a Swedish Control Bureau of Statistics forecast, the number of single persons aged 80 and older will increase by 40 percent by the turn of the century, at which point the total single population aged 80 and older will be 275,000. Special Forms of Housing for the Elderly In Sweden, pensioners' flats in ordinary blocks of flats, pen- sioners' homes, and service flats are examples of special solu- tions for the elderly within the framework of ordinary housing. Pensioners' flats in ordinary blocks are usually one- or two- roomers dispersed within a residential area. In 1975 there were about 22,000 such flats altogether, almost half of which were in the three metropolitan regions. The flats have varying stan- dards: some are poor and not easily accessible, but there are also
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 195 new and reconstructed flats with good accessibility. New produc- tion is on a small scale. There are also some 6,000 temporary pensioner flats, mostly in sparsely populated areas. In 1975 there were about 41,000 pensioners' flats in approxi- mately 2,500 pensioners' homes, most of them built before 1965; 80 percent were of the one-room-plus-kitchen/kitchenette type. Their standard varied greatly. Today, many of these homes are now closed down; some are being converted into service blocks. In the early 1970s the local councils began to build service blocks for pensioners as a complement to ordinary housing and old-age homes. In 1982 there were just over 500 service blocks with about 26,800 service flats ordinary flats but with access to a dining room, community and hobby rooms, social services, and medical care. The services offered by the service blocks vary according to the needs of the residents and to the block's prox- imity to the general services (e.g., post office, bank, social insur- ance office, library, cafeteria, and the like) available to all inhab- itants in the area. Several local councils have also combined service blocks with local nursing homes/health centers to share premises and staff and to provide care and services to the service block residents. The experience gained from the service blocks that have been built has led to a cutback in the plans for their extensions and to a reduction of the number of flats in them. During the period 1983-1987 the local councils planned nearly 400 building proj- ects with some 10,600 service flats. In the planned service blocks, about 40 flats is the most common construction goal but several of the local councils do not plan to incorporate more than 10 to 15 flats in order to avoid segregation. One-third of the projects are for reconstruction and additions to old-age homes. The Swedish Institutional Elderly Population Sweden is among the countries that have a large number of places in institutions in relation to the number of elderly. Nearly three-quarters of the total cost for care of the elderly goes to institutional care, with slightly more than one-quarter going to service and care in the home. Of the 7 percent of the elderly who live in institutions, a little more than half are in old-age homes. In 1982 there were about 1,100 old-age homes with some 56,500
196 SVEN THIBERG places. The size of the homes varies from 10 to more than 100 places. About half of the homes came into use after 1960. The average age of the residents is high about 83 years. In Sweden, the old-age homes are seen as a residential form for elderly persons who cannot look after themselves because their dwellings are uninhabitable or because they have a need for social assistance, or both. Staff are available around the clock. The pensioners have their own rooms, often with a toilet (72 percent) but seldom with a shower (12 percent); they also have access to a common dining room/sitting room. The stan- dard of the oldest homes is Tow compared with ordinary housing. The average size of rooms is 12 square meters. Of about 500 two- story old-age homes, in 1975 about 200 had no lift. In 350 homes a wheelchair user could not pass in or out through the outer door. The queues that had existed for places in the old-age homes are beginning to disappear; now, there are even vacant places. In fact, the number of places is falling by about 1,000 a year as the houses are being closed down or converted into service blocks with day centers, whose services catering and pedicure are available also to other pensioners in the neighborhood. Practi- cally no old-age homes are being built in Sweden today. Institutions for the Chronically Sick Nearly 4S,000 patients, 80 percent of whom are 75 years and older, are looked after in somatic long-term therapy. The hospi- taTization periods are Tong; according to the Association of County Councils' patient survey in 1983, every fourth patient had been hospitalized for more than 3 years. According to the 1974 policy program of the Swedish National Board of Health and Welfare, the main function of Tong-term therapy is to provide for the Tong-term needs of treatment, acti- vation, care, and nursing in as homelike a form as possible. Yet care is hardly a matter of homelike form in these institutions. The medical services have had a decisive influence on their organization and form. The standard of accommodation is very Tow. In 197S, according to the board, about 20 percent of the patients were in single rooms, 20 percent were in double rooms, 4 percent were in rooms with three beds, 40 percent were in rooms with four beds, and nearly ~ percent were in rooms with
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 197 five or more beds. About half of the rooms had only a washbasin; about 6 percent of the rooms had a toilet, washbasin, and bath/ shower. In about 4 percent of the rooms, there were no sanitary fixtures at all. About 2,800 patients had their own pictures, and around 1,000 had their own furniture. About 3,000 had radio, TV, and/or a tape recorder. Of the patients currently in long-term therapy, 20 percent could be discharged that is, according to a patient survey, they are judged to be no longer in need of treatment. That they have not been discharged may be due to several reasons: (1) they have no home to return to, (2) the housing conditions to which they could return are poor, (3) primary care and home help service is inadequate, and (4) they have no relatives who can help with care and nursing. A study by the Swedish National Board of Health and Welfare within the framework of the development of a policy program for future health and medical services (HS 90) reveals the inter- action between housing conditions and hospitalization: the util- ization of hospitals, the number of stays in hospitals, and the mean duration of hospitalization are correlated to the size of dwelling. The mean duration of care was longer for those who lived in small flats. The numbers of patients discharged in- creased with the size of their flat. Elderly persons living on their own consistently have longer stays in hospital and fewer dis- charges than people living together. It is often chance circumstances that decide whether an el derly person is institutionalized. Investigations show that trans- ferences of the elderly are sometimes made to an unnecessarily high level of care. Many people who should have been able to move to nursing homes or service blocks are today placed in long-term care. Others are forced to move to a nursing home from a casualty department while waiting for a place in a serv ice block. Studies show that there is great economic scope for an in- creased assignment of resources to care in the home. At Sunds- vall, where arrangements in the home have been sought for those waiting to enter institutions and service flats, the conse- quences after 3 years have been a certain surplus of places in institutions. There have been similar experiences at other places in the country.
198 SEEN THIBERG Psychiatric Institutions In October 1982, according to the National Board of Health and Welfare's patient survey, there were some 10,000 persons above 65 years of age in psychiatric care at institutions, the standard of accommodation at which is quite Tow. A trend toward less institutional forms of care, decentralization of resources to small units in people's local environment, and increased coordi- nation with the social services is one of the fundamental princi- ples for Swedish psychiatric care in the 1980s. Deinstitutionali- zation is thus a goal, and in the board's opinion, a substantial number of the persons now in psychiatric institutions could be discharged in the next few years, most to a normal dwelling with the support of the home help service and decentralized medical care. THE SWEDISH WAY OF CHANGE The official description of the progression of Swedish old-age policy development may be summed up as from the family, through the institution, to independent life. Historical studies have shown that the so-called extended fam- iTy has not been as commonplace nor as harmonious as nostalgia maintains. On the contrary, old people in an agricultural society had a difficult time. They were dependent on the young, and in a weak economy, they were set aside shut out and their rights were restricted. In reality, there was a "contract-out" system, a formal contract between children and parents. The contract stip- ulated the rights of the parents when they surrendered their property to the next generation. In rich farming families, those rights might consist of a dwelling of their own and free necessi- ties. If the family was poor, the rights and freedom of the old people were limited. In an agricultural society, it was common that poor or childless old people were "farmed out" in the com- munity to pay their way according to their ability by work. The poorhouse was the predecessor of the Swedish old-age home, which in due course became the standard solution of the housing problems of the elderly. The building of old-age homes began in 1944. No old-age homes are now being built, however, and the existing ones are being converted into new residential forms as the phasing-out of institutions continues. The nation's
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 199 housing policy for the elderly is directed toward independent living- in practice, remaining in one's dwelling on entry into the age of retirement. The question of institutionalization now crops up only when there is great need for continuous care. How great such care needs to be to necessitate institutionalization is a matter of dispute. Many experiments are now being conducted to evaluate home care as an alternative to institutionaTization. Various intermediate forms that offer alternatives to home care have also been developed for example, having one's own kitchen but also access to a dining room for collective meals. In conjunction with the current major reconstruction of the housing stock in Sweden-chiefly those dwellings built from the turn of the century up to the 1940s the question arises of the forms of dwellings for the elderly. This housing, which is situ- ated in the central and semicentral parts of the larger towns, is occupied chiefly by elderly persons. Reconstruction and modern- ization, therefore, are directed toward the improvement of the quality of housing (chiefly in regard to accessibility and sani- tary facilities) without forcing the occupants to move because of the work of reconstruction or increasing housing costs. The term "cautious reconstruction" has been coined and stands for the cautious handling of both the environment and the residents. In fact, cautiousness is often taken so far that consideration is paid to an individuaT's personal needs and desires, which has placed new requirements on organization and building methods that are in sharp contrast to the highly industrialized mass produc- tion technique the Swedish building industry developed during the so-called "million-flats program" during 1965-1975. In parallel with the change of methods for the conversion of the physical environment, a change is also taking place in Sweden in the methods of the care and service organization. This change is at least as radical as those that occur in the physical domain. There are two forms of organization that meet and are on the way to becoming integrated with one another. Home care is a practical service consisting of cleaning, shop- ping, cooking, walks, and social intercourse that the local coun- cil offers old people in accordance with an estimate of need made by the social authorities. Home nursing is provided by county council nursing personnel stationed in the so-called primary medical service. This form of care has always been offered but on a restricted scale. Earlier,
200 SVEN THIBERG when the need for care grew, the pensioner was quickly moved to an institution, usually an old-age home, but later to establish- ments for the chronically sick. Now, with old-age homes and institutions for the chronically sick being phased out, "heavy" care is increasingly assigned to local nursing homes. The chief tendency now, however, is to increase nursing service in the home and thus postpone or render unnecessary the move to an institution. It is also becoming increasingly common that, after temporary care in an institution for the chronically sick, per- haps following a transitional rehabilitation period, old people return to their normal accommodations with service and nurs ing in the home. In sum, the number of persons in Swedish institutions is being drastically reduced, and a rapidly growing proportion of old people live on in their homes until the end. Rehabilitation for a return to normal living becomes increasingly common at ever higher ages. In short, in Sweden, independent living in normal housing is now common practice. SCRUTINIZING THE GOALS Presented below is the structure of "societal prerequisites" and "aims of research" mentioned earlier in this paper, which are to be used as a mode] for the analysis of the social and built environment for the aged. The societal prerequisites can be di- vided into four main areas: (1) fundamental attitudes, (2) aims of housing policy, (3) aims in the provision of housing, and (4) aims of the medical and nursing services. The aims of research can be divided into three main areas: (1) research tasks, (2) the development of methods, and (3) the dis- semination of knowledge. Societal Prerequisites Fundamental attitudes should include the following: · The elderly are individuals with the same rights to inde- pendence, privacy, participation in community life, and security as persons of other ages. · The provisions of dwellings for the elderly shall in all essen- tial respects be based on a housing market common to all; and
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 201 · The housing market shall give the elderly a choice between different forms of dwellings and tenure to the same extent as other age categories. The aim of housing policy can be stated as follows: · The task of housing policy is, on the foundation of solidarity, to guarantee an abundant supply of forms of housing for all ages and types of households. · Forms of housing shall be made economically and techni- cally available through government financing and a govern- mental distribution policy. · The nideriv shall have their choice of dwelling according to ~ i/ _ . . . · ~ ~ ~ ~ ~ 1 fit _ 1 1 ~ 1 lo_ ~ _ ~ r need and desire and shall not be reterrect to Special forms OI residence as long as adequate care can be given to them in their own homes. The aim of housing provision involves these factors: · The existing housing stock shall be systematically con- verted to full accessibility by such methods and such financing as to make it easier for the elderly to remain in their homes. The modernization shall also comprise the external environ- ment, service establishments, and communications. · New housing efforts shall be directed toward strategic addi- tions to the existing stock. It is especially important to provide for new forms of living environments that are difficult to realize in existing housing and to guarantee a good housing standard for the older small households. · Both reconstruction and new construction shall be carried out with consideration given to the necessity of medical care for the elderly occurring to an increasing extent in their homes. Administration, maintenance, and care of the residential envi- ronment shall be of good quality and shall take place in close contact with the residents in order to increase well-being and security and reduce the risk of accidents. The aim of care services subsumes these areas: · Medical and health services, social services (home help), and local council consumer advisory services must be directed to- ward the provision of support and care in the home and the residential area. This focus will make it easier for the elderly to
202 SEEN THIBERG remain in their homes, and the need for institutional care will be reduced and directed toward the very oldest. · The care of the chronically ill must be humanized by decen- tralization, conversion into small units, and increased openness and flexibility. Coordination between the governing bodies and within the administration shall bridge the gap between nonin- stitutional and institutional care. The institutions shall func- tion as central points for noninstitutional care. · All forms of care shall have as their goal to give security and facilitate daily life and, at the same time, release the elderly person's own resources for independence. Voluntary efforts play an important role in this context. · Informal care- for example, by relatives shall be voluntary on the part of both giver and recipient and does not absolve society of its responsibility. Care by relatives shall be given the support and relief that are the precondition for quality services. · Staff development shall be directed to support for the changed view of care, to strengthening the capability of nursing staff, and to improving their working conditions and security of employment. Aim of Research The following research tasks should be pursued: · Increased attention shall be devoted to societal changes in the Tong and short term that have a significance for the elderly person's life and conditions. Of special interest is the study of economic, social, and cultural changes in society; knowledge of their origin and structural effect is basic to the development of Tong-term strategies. · Studies must be made of the environmental factors of impor- tance for the elderly person's living conditions, of methods for affecting them, and of ways to develop good alternatives. · Decision processes should be developed that allow the el- derly a greater influence over their environment and that better serve their interests. · The critical examination and evaluation of unusual solu- tions and experiments can be conducive to development and renewal. Methods development should include the following:
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 203 · Creative but critical use of today's unused data in files and survey studies, and the linked processing of data bases with respect for the privacy of the persons studied, are needed. · Methods for case studies should be developed as comple- ments to surveys on an aggregated level. Of special interest are different degrees of action in the research and mobilization of the elderly in studies of their own conditions. Combinations of hard and soft data are important. · The experience of those directly engaged in nursing and service delivery should be collected in categories that will make use of everyday field occurrences in the development of care methods and buildings. · Scientific methods and results should be examined as a ba- sis for the development of research capability and for relevance of the results as a basis for decisions; comparative studies are a step in the development of methods. The dissemination of knowledge should proceed in a number of ways: · Two-way communication is needed between the researchers and the surrounding world. · The development of new channels for dissemination of re- sults (e.g., through associations, trade union organizations, etc.) is needed. · New media for communication, such as video and educa- tional material, should be tried. CONCLUSION Even if it has not been stated outright, in both the United States and in Sweden, the question of an aging society is re- garded as a problem. It is assumed that significant social adjust- ments are required to solve this problem. The discussion sur- rounding this issue has been primarily concerned with which adjustments are required, how they can be implemented, which sacrifices are demanded, and what results can be expected. This is apparently so self-evident that no one has found it necessary to mention the basic issue. Yet, in order to formulate the initial problem, one can start from the postulate that the aging of society would be no problem if the aging of the individual were not problematic.
204 SVEN THIBERG It is possible to identify four frames of reference of problem areas under which many different questions about the aging of society and alternative solutions to the problems it seems to bring can be subsumed: · Economics The agingindividual is economically dependent on resources that have either been acquired earlier in life or that others must offer. · Social life The aging individual slides out of the social net- works offered by working life, family, and friends, and moves toward a growing state of isolation. · Cultural context The aging individual risks becoming es- tranged from the surrounding, rapidly changing society. · Functional independence-The aging individual requires more practical support, care, medical treatment, and a greater adaptation of the environment to his capacities than do other age groups. Both in Sweden and in the United States a large number of factors that fall within these frames of reference have been discussed. ~ find many similarities in the two countries in de- scriptions of the current situation and suggestions for action. Nevertheless, some important differences can be pointed out. One such difference is that the Swedish system of state welfare has been created with the objective of giving every elderly per- son, irrespective of his or her previous position in working life, an adequate economic base from which to maintain independ- ence. To that end, we have a comprehensive pension system, complemented by individual-oriented support and subsidies, that is intended to make the common society also accessible to the elderly. Another difference is that Swedish policies view the elderly as wishing to remain in their previous neighborhoods as Tong as possible. This is an area in which we offer flexible, versatile, and relatively generous individual support. In the Tong term, the individual's ability to remain in his or her former environ- ment is facilitated by methodically constructing housing, neigh- borhood services, and communications to be easily accessible to all. Economically and socially, development has been rapid, which can be seen from the changing patterns of consumption among the elderly and in the processes of deinstitutionalization and increasing mobility.
CROSS-NATIONAL PERSPECTIVES ON ENVIRONMENTS 205 On these two points, my North American colleagues have been less clear. Consequently, ~ hazard to assume that, in the United States, policy and thus perhaps also the work of research and development tend to focus on solving the problems of the elderly in isolation from other parts of society and other age categories. The two other frames of reference of this "problematization" are, relatively speaking, "emptier" in Swedish debate and re- search. As a formerly homogeneous society, we are unfamiliar with both social and cultural tensions and differences. Only in recent years has the inflow of foreign life-styTes and cultural patterns become so widespread that we can talk of a multicul- tural society. In addition, economic stratification is again in- creasing. The dearth of longitudinal studies has made it very difficult to determine what is happening at the individual level over time, as well as between generations and within society as a whole. Perhaps it is this lack of historical insight that has led us to treat the social and cultural implications of aging so clumsily in Sweden. On this point, the North American contributions to the study of this issue have been of particular interest to me. The question can be formulated: Do the opportunities for physical integration, which the Swedish system offers, also lead to social and cultural integration between generations and individuals? Our experience tells us that relations between relatives and work colleagues of the elderly are of such importance that it is difficult to compensate for their lack at advanced ages. For the elderly, to remain where they have always lived is the only available alternative, so as to maintain neighborly contacts built up in previous years. Beyond this point, we do not seem to know very much about what is actually happening other than that the generation that is elderly now is very much in favor of remaining in their accustomed housing. If ~ have correctly interpreted the North American studies, the attitude in this country is somewhat different. There is no hesi- tation about creating new environments for old people; indeed, they are expected to demonstrate a great capacity for adaptation and be capable of building up new networks together with other elderly people. Yet, considering the differences between various strata of the U.S. population, about which there has been rela- tively little discussion, it seems reasonable to assume that the very large range in the standard of living of the poorest and the
206 SEEN THIBERG middle classes in the United States ought to also be reflected in attitudes and not only in the conditions offered to the elderly. With these comments 1: approach what is my main impression of this conference: that we who work with the question of hous- ing for the elderly, both in Sweden and in the United States, have a backward-Iooking perspective rather than a cross-cul- tural one. There is something of a weakness in not being able to imagine the view of aging in an aging society that coming gen- erations will hold. During the last few decades the health and economy of elderly people in Sweden have dramatically improved, but neither work- ing life nor social and cultural patterns have adapted to these realities. Will this lead to a deepening of the generation gap? Can these social tensions lead to increased competition for social resources, compared to earlier generations, who "sacrificed" themselves for their children's well-being? Will the divisions found in our societies between different economic and social strata increase with age? Can society com- pensate those who do not succeed in building up resources for their old age during their working life? And finally, what is the actual role of the growing number of elderly in the developments that lie ahead?