I remember the evening 18 months ago when my parents and I returned home after my grandmother's cremation.
As the car pulled up, I looked at the terrace house we had lived in for more than 40 years and it seemed to sag with sorrow.
Grandma had spent hours on the porch, sitting in a wheelchair and playing with a deck of cards. But no more.
She lived to the ripe old age of 101 and though she had dementia in her later years, with all its effects of memory loss and confusion, she loved to drink beer and eat ice cream right to the end.
She spoke less and less as she aged but occasionally, she would communicate her feelings through hand gestures.
I still remember the thrill I felt some years back when I prepared a dish of Encik Kabin chicken, also known as Nonya fried chicken, and she flashed two thumbs up as she ate it. Since she had been an excellent Peranakan cook herself, I considered it high praise.
She was very much on my mind when I read recently of a new trend in rich and ageing countries of people sending their elderly relatives across the border to low-cost nursing homes in less developed parts of the world. The trend even has its own catchphrase - Grandma export.
The Germans have been exporting grandma to Poland, Hungary, the Czech Republic and Slovakia. The Swiss and the British to Thailand. The Americans to the Philippines.
It is a practice that provokes strong emotions, with Munich's leading newspaper Sueddeutsche Zeitung denouncing it as "gerontological colonialism", and comparing it to nations exporting their trash.
But when I read the personal stories of middle-aged children who had to make the difficult decision to send their elderly parents to another country, what I felt was not anger but sadness.
I read accounts of children who tried several other options before agonising over whether to move their parent abroad. Those who chose to did so because the foreign home provided care of a quality they could not afford at home.
Cost was also the top-of-mind concern back in 2009 when then Health Minister Khaw Boon Wan raised this issue in Parliament. He proposed nursing homes in Johor Baru as an option for middle-income families with elderly relatives in need of care, but who do not qualify for hefty government subsidies to help them foot the bill for local homes.
He had spoken to a Singaporean investor building a nursing home across the Causeway and was struck by how low the land and construction costs were there as compared with Singapore; so low, he said, as to be "mind-boggling".
But his comments triggered a torrent of angry responses, with some people jumping to the wrong conclusion that the Government planned to ship poor, old folk to Johor Baru.
Today, six years later, the option Mr Khaw raised has become a reality for dozens of Singaporeans who need nursing care because they are old or ill. That is due both to Singapore's shortage of nursing home places and a large cost differential.
A bed in a nursing home in Johor Baru costs about $600 a month, much lower than fees in Singapore which range from $1,200 to $3,500, before subsidies. The homes in Johor Baru also tend to be more spacious, with single or two-bedder rooms the norm, instead of the six- to eight-bedders common here.
In terms of economics, moving a senior to Johor Baru makes good sense.
But what is less obvious is the human cost of this relocation, which is also - for the senior and his or her family - a wrenching dislocation.
As Miss Tan Li Feng wrote in a letter to The Straits Times Forum Page in 2009, "spending one's golden years institutionalised in another country is a great blow to one's self-worth and dignity".
It is painful even for seniors with dementia, and who appear not able to tell whether they are at home or in another country.
In a well-researched commentary on the trend of Grandma export, my colleague, Janice Tai, quoted senior social worker Jasmine Wong from the Hua Mei Centre for Successful Ageing, who said that dementia patients benefit from being in familiar surroundings.
"Persons with dementia retain old memories while struggling with recent events - so being in a familiar place helps relieve their anxiety and familial visits play an important part in that assurance," Ms Wong said.
Beyond the cost to seniors, family members also pay a price when they keep a distance between themselves and their elders. That is so whether one's parent is in a nursing home in JB or in Singapore, or living in a flat across the island.
I once met a woman who ran a local nursing home and whose heart bled for the residents abandoned by their children. She would call these children and plead with them to visit their parents, never mind the unpaid bills she thought might be keeping some away.
So what is the intangible cost of staying away from one's parents when they have become too old to be useful?
For one thing, we give up the chance to learn from those who have lived longer than we have. A few months after my grandmother died, I caught a television programme on ageing in which an expert said young people who grew up with their grandparents tended to have a less negative view of growing old.
I also read a book by American radio journalist Neenah Ellis, entitled If I Live To Be 100. She took a year to record the interviews for the book, travelling across the US and spending days at a stretch with centenarians in various parts of the country.
"In my early conversations with them, I was too focused on their physical problems," she wrote in the book's introduction. "I was too often in a hurry, looking for facts instead of truth. I was embarrassed to ask about sex, afraid to ask about death, and assumed I could not come right out with 'What is the meaning of life?' And I was uncomfortable with silence.
"But I got better. And as I tried to put what I learnt from the centenarians into those monthly nine-minute radio stories, I realised I wouldn't get my answers by asking questions. I would get them by waiting."
She reminded me of the valuable life lessons to be learnt through spending time with seniors. But the burden of caregiving is a heavy one, and it can break those who lack support.
That is why I hope that all of us - the state, the community and individuals in our capacity as family members and neighbours - can help those who struggle to care for elderly parents or relatives, so we can continue to keep our seniors close by.
This article was first published on Apr 19, 2015.
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