The EconomistAugust 29th 2020 Special reportDementia 92
Thelastresort
CHIANG MAI AND PHUKET
For the best care, well-off Europeans with dementia in the family are looking abroadI
n 2001, whenMartin Woodtli’s mother
was diagnosed with Alzheimer’s, he
was living in his native Switzerland. His
father, who had a history of depression,
had found himself living with a partner
who no longer always knew who he was.
He killed himself the next year. An only
child, Mr Woodtli quit his job with a
refugee-integration service, to become a
full-time caregiver. He looked at care
homes, but did not like them. His neigh-
bours were sympathetic, but rather
disapproving of a man in his 40s ditch-
ing his career to “waste his life” in this
way. He thought of moving with his
mother to Chiang Mai, a town of 127,000
in northern Thailand, where he had once
worked on anaidsproject for Médecins
Sans Frontières, an ngo.
He sought help from nurses through a
local hospital, but then realised that his
mother needed companions more than
trained medical care, and for 24 hours a
day. She was soon well looked after. He
found a job, but it would have meant
moving. He began to wonder if in fact he
already had one: his experience with his
mother might be the basis for a business.
It was. He found other clients, and a
number of properties in a “village”—a
Chiang Mai suburb. Now he runs a small
but successful operation. Fourteen Euro-
peans with dementia live there, mainly
Swiss and Germans, all with access to
24-hour attention from one of the three
carers dedicated to each of them, an
unthinkable arrangement for all but the
richest of the rich in Europe. In normal
times (but not during the pandemic) they
eat breakfast and lunch together in oneof the houses and evening meals on their
own. They have a swimming pool and a
shop, used by the whole village. The Swiss
wife of one resident lives nearby and
describes the enormous improvement in
her husband since their arrival. His bouts
of physical aggression are over; he is tak-
ing less medication.
It is as close to a normal life as those
with severe dementia are likely to find—
except that it is far away from the homes
and culture (and language) they knew.
Their families, says Caleb Johnston of
Newcastle University, who with Geraldine
Pratt of the University of British Columbia
in Vancouver, has researched the business,
can be defensive. Yet guilt over having
shipped their elderly to the other side of
the world, where visiting is much harder,
may be assuaged by the higher standards
of care available at much lower cost.
Mr Woodtli is the unlikely founder of amini-industry, in facilities marketing
dementia care to foreigners, of which
there are perhaps a dozen. Others, such as
one run by two more Swiss expatriates,
Carlo and Anita Somaini, on the island of
Phuket, look more like luxury holiday
resorts—but theirs has two emergency
rooms for its 16 guests. The Somainis are
branching into home care, offering home
visits from trained dementia nurses.
Scaling up such operations is hard.
Vivobene, a “long-stay resort with inte-
grated care” 18km outside Chiang Mai, had
some 50 residents, just over half with
dementia. Carers outnumbered residents.
It offered patient-centred care, based on
the ideas of the late Thomas Kitwood, a
British pioneer in dementia research,
which call for a flexible approach based on
individual needs, not a uniform set of
daily targets (for walking, washing and
eating). But a disagreement with the own-
ers led the Swiss-directed medical and
other staff to leave, taking most of the
nursing residents with them to a new
facility, to be known as “VivoCare”.
The number of dementia tourists in
Thailand may be 150, mainly Americans,
Britons, Germans and Italians. (Other
countries such as Costa Rica, Mexico and
the Philippines also have care homes for
expatriates.) Mr Woodtli criticises some
for merely adapting a failed model of
large-scale care centres from the rich
world. Rather, the method he devised for
his mother shows what can be done to
offer dementia patients the best individual
care with a large number of skilled, dedi-
cated, low-wage carers—and how far out of
reach that is for most of the world.find enoughpeople willing and able to take on the job.
This is partly a simple function of demography as society ages.
But it is also partly because care workers often endure low status
and low pay, a sad truth highlighted in the covid-19 pandemic as
society leant on them more heavily than ever. In Britain, for exam-
ple, under the new immigration policy the government is intro-
ducing for the post-Brexit world, most jobs in care will not pay
high enough wages to allow employers to recruit overseas. Yet the
industry relies on about 350,000 immigrant workers. A trade un-
ion has warned of a shortage of up to 500,000 workers in an indus-
try that already has 8% of vacancies unfilled.
The ranking of such jobs as “unskilled” seems short-sighted.
Camilla Cavendish, a journalist and policy wonk now again advis-
ing the government, led a review in 2013 of support workers in Brit-
ain’s health and social-care services. In a recent book (“Extra Time:
Ten Lessons for an Ageing World”), she writes: “Care work is un-
dervalued, underpaid, emotionally draining and physically ex-hausting. Yet it is, in my view, highly skilled. It requires enormous
maturity and resilience; deep wells of kindness, too.”
Japan, in contrast, has been making it easier for foreign work-
ers to come in for a few years. But cultural and language barriers
are high, and the country starts from such a low base of immigra-
tion that this will not make much of a dent in its shortfall.
Adelina Comas-Herrera, a researcher at the London School of
Economics, is leading a study into care in poorer countries
(“Strengthening Responses to Dementia in Developing Countries”
or stride). She argues that what is needed, given the looming la-
bour crunch, is a new model of collaborative care. This might in-
volve using what institutional infrastructure exists for new pur-
poses, especially in poor countries with few arrangements in
place. In Vietnam, for example, the ruling Communist Party has a
nationwide network of offices. Community centres might be
transformed to offer a form of day care. Such adaptation may be
better than building dementia-care services from scratch. 7