Outsourcing the elderly: Low-cost care, made in India

PONDICHERRY, India — After three years of caring for his increasingly frail mother and father in their Florida retirement home, Steve Herzfeld was exhausted and faced with spending his family's last resources to put the couple in an affordable nursing home.

So he made what he saw as the only sensible decision: He "outsourced" his parents to India.

His 89-year-old mother, Frances, who suffers from advanced Parkinson's disease, now receives daily massages, physical therapy and 24-hour help getting to the bathroom, all for about $15 a day. His father, Ernest, 93, an Alzheimer's patient, has a full-time personal assistant and a cook who has won him over to a vegetarian diet healthful enough that he no longer needs cholesterol medication.

Best of all, the plentiful drugs the couple require cost less than 20 percent of what they do at home, and salaries for their six-person staff are so low that the pair now bank $1,000 a month of their $3,000 Social Security payment. They aim to use the savings as an emergency fund, or to pay for airline tickets if family members want to visit.

"I wouldn't say it's a solution for everybody, but I consider it the best solution to our problem," said Herzfeld, 56, a management expert who made the move to India with his parents, and now, as "care manager rather than the actual worker" has time for things such as bike rides to the grocery and strolls in the botanical gardens with his father.

The outsourcing of medical care to India already includes limited use of Indian radiology technicians to read X-rays digitally transmitted from U.S. hospitals, as well as a number of surgical procedures performed more cheaply in India and other Asian nations.

With the cost of nursing homes, home nurses and medications painfully high in the United States, the elderly and their caregivers long have looked abroad for better solutions. Many families now drive regularly to Mexico or Canada to buy more affordable drugs, or hire recent immigrants — some of them illegal — to help them look after frail parents.

A growing number of aging couples have bought retirement homes in Mexico, where help is cheap and Medicare-funded health care a quick drive across the border.

Herzfeld never thought he'd head abroad, too. When his mother broke a hip in 2004, he drove to their home in Pompano Beach from his home in North Carolina, figuring he'd stay awhile and help his parents get back on their feet. But like so many other caregivers, he found himself still on the couch in his parents' spare bedroom three years later, wondering where his life had gone and how he was going to find the energy to go on.

"I started to see him breaking down after three years working 24 hours a day," said longtime friend Eric Shaffer, who runs an international software design firm with offices around the world, including one in Pondicherry, a former French colony on India's southern coast. "He was in a chess game with no move. Nothing was good."

At wit's end, Herzfeld began investigating nursing homes, but found that the $6,600-a-month cost at the cheapest one he could find near family members would bankrupt his parents quickly. Herzfeld's father also refused to take what he called "welfare" from his family or from the government.

Herzfeld had other concerns: "I've seen nursing homes, and it's a hell of a way to end your life," he said. "I wouldn't want someone to do that to me."

So when Shaffer suggested by phone that Herzfeld consider a move to India, "I said right away, 'There's an idea!' " he said.

Herzfeld, single and a longtime follower of Transcendental Meditation, previously had spent five years in India, first studying and later teaching courses on management at an MBA program in Hyderabad. He admired India's longtime, though recently slipping, respect for the elderly, and he quickly realized that Pondicherry — a haven for aging hippies from around the world — might just work.

The graceful old town, with its orange-blooming flamboyant trees and coconut palms, was foreigner-friendly and on the ocean, a big attraction for his father. The weather was much like Florida's, and many people spoke French, a language his Swiss-born father speaks fluently. Best of all, nursing care and rent were cheap, and Shaffer already was there, promising to help rent a house and hire staff. Herzfeld decided to make the move.

Hours after arriving in India, Herzfeld's jet-lagged father tried to chase his new Indian personal aide out of the bathroom — the youth had been instructed to help him with the toilet — and fell, cracking his head on the bathtub. The family spent the first night in the hospital as Ernest was stitched up.

The three also had a few bouts with India's infamous intestinal bugs as they adjusted to a new diet, and Ernest broke his nose when he tripped over his aide — diligently sleeping just outside the bedroom door — on a midnight refrigerator raid.

Eight months later, however, the family is settled in.

Herzfeld's mother has a daily hourlong session with a physical therapist, who flexes her stiff legs and gets her up on her feet briefly with a walker. A nurse, on duty all day, braids flowers into the old woman's gray hair, massages her legs and arms, holds her hand while she watches television and feeds her meals. A massage therapist gives both of the aged Americans a daily full-body massage, and a cook fixes them simple Indian meals.

Ernest spends much of the day watching cable television in an overstuffed chair, reading a couple of local English-language papers. He sometimes catches a rickshaw to the beach or botanic gardens with his aide or his son.

Asked how he likes India, he says he has seen enough and is "ready for a change." But he admits to liking the food and speaking French, not to mention the pretty, young sari-clad attendants hovering around him.

But India, where life expectancy still hovers around 60 years, lacks many physicians experienced in gerontology. The family keeps in touch with relatives and friends via e-mail and Internet videophone but hasn't persuaded anybody to visit.

"They still think of India as being on another planet," Herzfeld said, speaking of family and friends. "It's a step above asking them to come to Baghdad, but not much."

Every time he looks at the bills — less than $2,000 a month for food, rent, utilities, medications, phones and 24-hour staffing — Herzfeld thinks he's done the right thing for his parents and himself.

"It can be done," he said. "This is working."