With luck, either you will grow old or you already have. That is my ambition and probably yours, and yet with each year we succeed in surviving, we all face a crescendo of mockery, disdain, and neglect. Ageism is the most paradoxical form of bigotry. Rather than expressing contempt for others, it lashes out at our own futures. It expresses itself in innumerable ways — in the eagerness to sacrifice the elderly on the altar of the economy, in the willingness to keep them confined while everyone else emerges from their shells, and, in a popular culture that sees old age (when it sees it at all) as a purgatory of bingo nights. Stephen Colbert turned the notion of a 75-year-old antifa into a comic riff on geriatric terrorists, replete with images of octogenarians innocently locomoting with walkers, stair lifts, and golf carts.
In Sweden, elderly COVID patients were denied hospitalization, and in some cases palliative care edged over into “active euthanasia,” which seems barely distinguishable from execution. The Wall Street Journal quotes a nurse, Latifa Löfvenberg: “People suffocated, it was horrible to watch. One patient asked me what I was giving him when I gave him the morphine injection, and I lied to him. Many died before their time. It was very, very difficult.”
In this country, we have erected a vast apparatus of last-stop living arrangements that, during the pandemic, have proven remarkably successful at killing the very people they were supposed to care for. The disease that has roared through nursing homes is forcing us to look hard at a system we use to store large populations and recognize that, like prisons and segregated schools, it brings us shame.
The job of housing the old sits at the juncture of social services, the medical establishment, the welfare system, and the real-estate business. Those industries have come together to spawn another, geared mostly to affluent planners-ahead. With enough money and foresight, you can outfit your homes for your changing needs, hire staff, or perhaps sell some property to pay for a move into a deluxe assisted-living facility, a cross between a condo and a hotel with room-service doctors. “I don’t think the industry has pushed itself to advocate for the highly frail or the people needing higher levels of care and support,” USC architecture professor Victor Regnier told an interviewer in 2018. “Many providers are happy to settle for mildly impaired individuals that can afford their services.” In other words, if you’re a sick, old person who’s not too old, not too sick, and not too poor, you’re golden. For everyone else, there are nursing homes.
The nursing-home system is an obsolete mess that emerged out of a bureaucratic misconception. In 1946, Congress passed the Hill-Burton Act, which paid to modernize hospitals that agreed to provide free or low-cost care. In 1954, the law was expanded to cover nursing homes, which consolidated the medicalization of senior care. Federal money summoned a wave of new nursing homes, which were built like hospitals, regulated by public-health authorities, and designed to deliver medical care with maximal efficiency and minimal cost. They reflect, reinforce, and perhaps resulted in, a society that pathologizes old age.
The government sees its mission as preventing the worst outcomes: controlling waste, preventing elder abuse, and minimizing unnecessary death. Traditional nursing homes, with their medical stations and long corridors, are designed for a constantly changing staff to circulate among residents who, ideally, remain inert, confined to beds that take up most of their assigned square footage. As in hospitals, two people share a room and a mini-bathroom with a toilet and a sink. Social life, dining, activities, and exercise are mostly regimented and take place in common areas, where dozens, even hundreds, of residents can get together and swap deadly germs. The whole apparatus is ideally suited to propagating infectious disease. David Grabowski, a professor of health-care policy at Harvard Medical School, and a team of researchers analyzed the spread of COVID-19 in nursing homes, and concluded that it didn’t matter whether they were well or shoddily managed, or if the population was rich or poor; if the virus was circulating outside the doors, staff almost invariably brought it inside. This wasn’t a bad-apples problem; it was systemic dysfunction.
Even when there is no pandemic to worry about, most of these places have pared existence for the long-lived back to its grim essentials. These are places nobody would choose to die. More important, they are places nobody would choose to live. “People ask me, ‘After COVID, is anyone going to want to go into a nursing home ever again?’ The answer is: Nobody ever wanted to go to one,” Grabowski says. And yet 1.5 million people do, mostly because they have no other choice. “If we’d seen a different way, maybe we’d have a different attitude about them,” Grabowski adds.
The fact that we haven’t represents a colossal failure of imagination — worse, it’s the triumph of indifference. “We baby boomers thought we would die without ever getting old,” says Dan Reingold, the CEO of RiverSpring Health, which runs the Hebrew Home in Riverdale. “We upended every other system — suburbia, education, child-rearing, college campuses — but not long-term care. Now the pandemic is forcing us to take care of the design and delivery of long-term care just as the baby boomers are about to overwhelm the system.”
Most of us fantasize about aging in place: dying in the homes we have lived in for decades, with the occasional assist from friends, family, and good-hearted neighbors. The problem is not just that home care can be viciously expensive, or that stairs, bathtubs, and stoves pose new dangers as their owners age. It’s also that, in most places, living alone is deadly. When a longtime suburbanite loses the ability to drive, a car-dependent neighborhood can turn into a verdant prison, stranding the elderly indoors without access to public transit, shops, or even sidewalks. “Social isolation kills people,” Reingold says. “It’s the equivalent of smoking two packs a day. A colleague said something profound: ‘A lot of people are going to die of COVID who never got the coronavirus.’ ”
It’s not as if the only alternative to staying at home is a soul-sapping institution. Back when people traveled for pleasure, tourists regularly visited the Royal Hospital Chelsea in London, where, since the end of the 17th century, veterans have been able to trade in a military pension for a lifelong berth in a soldiers’ collective on an architecturally exquisite campus, located amid some of the city’s most expensive real estate. Those who can work tending the grounds, staffing the small museum, and leading tours. When health crises hit, they can move into the care home, which is on the grounds, overlooking immaculate gardens.
The example of an institution so humane that it seems almost wastefully archaic suggests that we don’t need to reinvent the nursing home, only build on humane principles that already succeed.
In Sweden, elderly COVID patients were denied hospitalization, and in some cases palliative care edged over into “active euthanasia,” which seems barely distinguishable from execution. The Wall Street Journal quotes a nurse, Latifa Löfvenberg: “People suffocated, it was horrible to watch. One patient asked me what I was giving him when I gave him the morphine injection, and I lied to him. Many died before their time. It was very, very difficult.”
In this country, we have erected a vast apparatus of last-stop living arrangements that, during the pandemic, have proven remarkably successful at killing the very people they were supposed to care for. The disease that has roared through nursing homes is forcing us to look hard at a system we use to store large populations and recognize that, like prisons and segregated schools, it brings us shame.The job of housing the old sits at the juncture of social services, the medical establishment, the welfare system, and the real-estate business. Those industries have come together to spawn another, geared mostly to affluent planners-ahead. With enough money and foresight, you can outfit your homes for your changing needs, hire staff, or perhaps sell some property to pay for a move into a deluxe assisted-living facility, a cross between a condo and a hotel with room-service doctors. “I don’t think the industry has pushed itself to advocate for the highly frail or the people needing higher levels of care and support,” USC architecture professor Victor Regnier told an interviewer in 2018. “Many providers are happy to settle for mildly impaired individuals that can afford their services.” In other words, if you’re a sick, old person who’s not too old, not too sick, and not too poor, you’re golden. For everyone else, there are nursing homes.
The nursing-home system is an obsolete mess that emerged out of a bureaucratic misconception. In 1946, Congress passed the Hill-Burton Act, which paid to modernize hospitals that agreed to provide free or low-cost care. In 1954, the law was expanded to cover nursing homes, which consolidated the medicalization of senior care. Federal money summoned a wave of new nursing homes, which were built like hospitals, regulated by public-health authorities, and designed to deliver medical care with maximal efficiency and minimal cost. They reflect, reinforce, and perhaps resulted in, a society that pathologizes old age.
The government sees its mission as preventing the worst outcomes: controlling waste, preventing elder abuse, and minimizing unnecessary death. Traditional nursing homes, with their medical stations and long corridors, are designed for a constantly changing staff to circulate among residents who, ideally, remain inert, confined to beds that take up most of their assigned square footage. As in hospitals, two people share a room and a mini-bathroom with a toilet and a sink. Social life, dining, activities, and exercise are mostly regimented and take place in common areas, where dozens, even hundreds, of residents can get together and swap deadly germs. The whole apparatus is ideally suited to propagating infectious disease. David Grabowski, a professor of health-care policy at Harvard Medical School, and a team of researchers analyzed the spread of COVID-19 in nursing homes, and concluded that it didn’t matter whether they were well or shoddily managed, or if the population was rich or poor; if the virus was circulating outside the doors, staff almost invariably brought it inside. This wasn’t a bad-apples problem; it was systemic dysfunction.
Even when there is no pandemic to worry about, most of these places have pared existence for the long-lived back to its grim essentials. These are places nobody would choose to die. More important, they are places nobody would choose to live. “People ask me, ‘After COVID, is anyone going to want to go into a nursing home ever again?’ The answer is: Nobody ever wanted to go to one,” Grabowski says. And yet 1.5 million people do, mostly because they have no other choice. “If we’d seen a different way, maybe we’d have a different attitude about them,” Grabowski adds.
The fact that we haven’t represents a colossal failure of imagination — worse, it’s the triumph of indifference. “We baby boomers thought we would die without ever getting old,” says Dan Reingold, the CEO of RiverSpring Health, which runs the Hebrew Home in Riverdale. “We upended every other system — suburbia, education, child-rearing, college campuses — but not long-term care. Now the pandemic is forcing us to take care of the design and delivery of long-term care just as the baby boomers are about to overwhelm the system.”
Most of us fantasize about aging in place: dying in the homes we have lived in for decades, with the occasional assist from friends, family, and good-hearted neighbors. The problem is not just that home care can be viciously expensive, or that stairs, bathtubs, and stoves pose new dangers as their owners age. It’s also that, in most places, living alone is deadly. When a longtime suburbanite loses the ability to drive, a car-dependent neighborhood can turn into a verdant prison, stranding the elderly indoors without access to public transit, shops, or even sidewalks. “Social isolation kills people,” Reingold says. “It’s the equivalent of smoking two packs a day. A colleague said something profound: ‘A lot of people are going to die of COVID who never got the coronavirus.’ ”
It’s not as if the only alternative to staying at home is a soul-sapping institution. Back when people traveled for pleasure, tourists regularly visited the Royal Hospital Chelsea in London, where, since the end of the 17th century, veterans have been able to trade in a military pension for a lifelong berth in a soldiers’ collective on an architecturally exquisite campus, located amid some of the city’s most expensive real estate. Those who can work tending the grounds, staffing the small museum, and leading tours. When health crises hit, they can move into the care home, which is on the grounds, overlooking immaculate gardens.
The example of an institution so humane that it seems almost wastefully archaic suggests that we don’t need to reinvent the nursing home, only build on humane principles that already succeed.
by Justin Davidson, NY Mag/Intelligencer | Read more:
Image: C.F. Møller
[ed. Personally, I'd prefer an endless supply of good drugs, or something like the euthanasia scene in Soylent Green - Death of Sol (not available on YouTube for some reason).]
