Every day at 6 a.m., Sunil Pande phones his parents in Gurgaon, India, which is part of New Delhi.
If his 92-year-old father and his 85-year-old mother sound well, his day proceeds normally. But if something seems dangerously amiss, he has a difficult decision to make.
Mr. Pande, 55 and an only child, lives in Portland, Ore. The last plane out of the city that gets him to New Delhi within 24 hours leaves at 11 a.m. When a crisis appears imminent — a judgment call he must make from 7,000 miles away — he'll drop everything, get on the plane and rush to his parents' side.
The last time that happened was about a year ago. Mr. Pande's father, Chandra Shekhar Pande, had stopped recognizing people and sounded incoherent on the telephone. He is prone to urinary tract infections, and the younger Mr. Pande feared an infection was raging out of control.
Mr. Pande hopped on a flight and remained in India for a month, seeing his father through a 10-day hospitalization and an extended recovery. (In India, he said, it's expected that a family member or friend will stay with a hospital patient 24/7, serving as an unpaid attendant.)
How many people who come to America for an education or a job and stay eventually become transnational caregivers — people who care for relatives or friends across national boundaries? No one really knows. But there's certainly a long tradition of cross-border family interactions in this nation of immigrants.
Both historically and today, financial support from people who come to the United States flows to relatives across oceans, and south to Mexico and Central and Latin America. Some immigrants spend parts of the year here and in their countries of origin, looking after young children or older parents left behind.
But the dynamics of these arrangements are different now because of two major trends. Across the world, people are living longer: more immigrants have aging relatives in distant lands in their 70s, 80s or 90s, with all the related medical and social issues.
Meanwhile, technology has transformed how people can communicate over long distances and altered expectations of what people can do for far-flung relatives. Whereas letters once took weeks to cross an ocean and phone service was scarce in Africa, Asia and rural areas of other continents, today video chats occur in real-time and almost everyone has cellphones.
Erica Dhar, a senior advisor at AARP's office of international affairs, wrote her graduate thesis on transnational caregiving, a topic she became interested in while living in New York City and trying to look after her elderly mother, Verna Pinto, in New Delhi.
For a decade, until her mother's death in January 2012, her habit was to visit India once or twice a year and call each morning before going to work. Gradually, Ms. Dhar became aware her very energetic, very independent mother was developing dementia.
"She would say 'I'm so lonely. When are you coming to visit?,' and the guilt would kick in because you know she's alone and you feel responsible," said Ms. Dhar, who said she came to dread the morning conversations.
In India, it is considered shameful to send an elderly relative to a nursing home; instead, domestic workers — often from rural areas, with no education — care for older people in their homes. When her mother started deteriorating, Ms. Dhar would call the domestic helpers to try to get information about what was going on. It wasn't easy.
During those years, there was no such thing as vacation. If Ms. Dhar had time off, she'd travel to India and spend all her time off there. Managing the expenses, the time and the family relationships — Ms. Dhar has two sisters, one in Canada and one in India — presented constant challenges.
Complicating matters even further is a lack of geriatric training for doctors in India, the absence of home health care services and an entirely different set of medical services. "You get the call — Mom is in terrible shape. You jump on a plane, you arrive stressed and jet-lagged, and now you have to deal with a health care and insurance system that's not at all familiar," Ms. Dhar said.
In these situations, people often turn for help to friends from their neighborhood or from high school and college. When there's an emergency, "I'll call someone, usually from college, and tell them 'I'll be there tomorrow. Can you go over and help take care of things before I arrive?'" Mr. Pande said.
He is a computer scientist who visited India five times last year, combining vacation with business travel whenever possible.
He manages his parents' medical care as best he can. Every week, his father has urine tests meant to identify the first signs of an infection; Mr. Pande's aunt takes a photo of the test results on her iPad and sends them to Mr. Pande, who keeps a running record on his iPad and his computer.
Should test values appear out of whack, Mr. Pande will then e-mail the results to his father's doctor, who usually calls to discuss the next steps.
Two months ago, when an infection actually erupted, Mr. Pande set an alarm on his smart phone each time his father was due to take medication. When it went off, he called India to check that the medication was administered as ordered. "There is a sophisticated orchestration of care that has to happen," Mr. Pande said.
When his 75-year-old aunt, who is caring for his parents, has her own medical issues, "I have to figure out who's going to be at home with my parents and who's going to be with my aunt at the hospital." A long-time family cook can help, but that involves walking him through what needs to be done "step by step on the iPad," he said.
Asked whether this routine takes a toll, Mr. Pande, who is married and has a teenage daughter, said, "it's not rocket science. Someone has to do it."
A cousin, also living in Portland, faces many of the same caregiving challenges. For the past several years, he has taken consulting jobs, so he can travel to India every three months, staying for up to six weeks. "He's decided he can't have a regular job," Mr. Pande said.
For her part, Ms. Dhar said she had three close girlfriends who are currently traveling back and forth to India whenever possible, and Skyping and calling elderly parents daily when they're back in the United States. "With increasing longevity and globalization, this is going to be a growing issue," she said.
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