Do We Mistreat the Elderly in America?
Ira Byock, MD was the Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and is currently Professor of Anesthesiology and Community & Family Medicine at Dartmouth Medical School.
Dr. Byock has authored numerous articles on the ethics and practice of hospice, palliative and end-of-life care. His first book, Dying Well, (1997) has become a standard in the field. His most recent book, The Four Things That Matter Most, (2004) is used as a counseling tool widely by palliative care and hospice programs, as well as within pastoral care.
Dr. Byock has been a consistent advocate for the voice and rights of dying patients and their families. He has been the recipient of the National Hospice Organization’s Person of the Year (1995), the National Coalition of Cancer Survivorship’s Natalie Davis Spingarn Writers Award (2000), the American College of CHEST Physicians Roger Bone Memorial Lecture Award (2003) and the Outstanding Colleague Award (2008) of the National Association of Catholic Chaplains.
Question: Do we mistreat the elderly?
Ira Byock: Yeah, I think contemporary America deeply mistreats the elderly in so many ways, I think ageism is alive and well in the United States in our culture. I think the way we fund and staff nursing homes is an absolute national disgrace, it’s a abomination. And if it was really known and understood, we wouldn’t be able to live with ourselves, I think this becomes a political issue very quickly, because we all tolerate this, we are all – we are all complicit in the neglect frankly the engendered acculturated neglect that occurs not only for the elderly but for anybody who is physically dependent, physically seriously disabled, or seriously ill and dying. It’s as if they remind us of our mortality, and so we don’t want them around.
I think to a large extend frankly, our nursing homes today function as warehouses that actually have a cultural function, though it’s an embarrassing one of segregating people who are ill infirm demented or just playing frail and elderly, keeping them out of our sight. We hire entry level workers, we often don’t pay those workers a living wage, there are far too few of them to take care of the people who live there. And yet these are our grandparents and our parents and our brothers and sisters, some places there are children. And it is so not okay, that really if – many people could see what I have seen and know what I know about nursing homes, you would think that we would be out in the streets demanding better care to start with better staffing of the nursing home and better support for the people who work in them.
Ira Byock: Well, I think people who work in nursing homes are truly heroes in America today, and I want to distinguish the systemic neglect of nursing homes and the systemic lack of support for nursing homes from the people who work within them, they are some of the most committed people I know, but nursing homes are understaffed, every study that’s ever been done has shown that they are woefully understaffed, in some studies even governmental studies, they show that 90% of nursing homes are understaffed and many, many residents of nursing homes are seriously malnourished, starving, not because they can't eat, or don’t want to eat, but because they need help in eating, and there is simply not enough aids to help the residents of nursing homes eat at meal time. In some studies it’s a ratio of 15 people who need help in eating at meal times for each one aid to help them eat.
This is a national disgrace, and unless or until we can staff our nursing homes at levels that are at least at a safe and prudent level, I would say we can’t build another highway, we can’t fix another pothole in the highways we have, we can't make another even high-minded adventure overseas in our military or anything. We have to take care of our grandparents and our parents, but we are not at this point. And I don’t understand and I have been part of efforts in New Hampshire to bring this to the attention of presidential primary candidates, we have huge support from the citizen tree [phonetic] of New Hampshire to make these issues a priority, please visit: reclaimtheend.org, remarkable citizen initiative that I was part of, but we haven't done it yet, and noticed it’s not a top tier issue in the presidential campaign, but it is endemic issue.
And it gets even worse, I would say that we have a crisis that surrounds the way we care for people, and the way people spend the last chapter of the lives and the way they die today. But unless we act, these will be good old days. We will look back on the way we cared for people today, we will look back at today’s nursing homes, and they will in retrospect look like luxury hotels. We boomers may well yet live to see real human ware houses from the inside.
Question: How do we fix it?
Ira Byock: Well, the irony here is that, these are all correctable problems. This is not rocket science clinically or, from a health systems perspective, and it’s really not even that expensive to do this well. When 20% of Americans are dying in ICUs, when 50% of Americans are dying in hospitals, what we spend is much on the last part of last year of life as we spend on in the rest of healthcare for any given individual, at least to their adulthood. We can care well for people through the end of life, we have to stop avoiding death as if it were optional and begin to actually look at what a package of services and living situation, patients with their families need to live a full and healthy life.
That doesn’t mean we have to implant electrical defibrillators in every body. It doesn’t mean that we necessarily have to provide 4th, 5th and 6 layer chemotherapy to every body, but it does mean that we have to staff our nursing home, so that our parents and grandparents have somebody to answer the bell if I need to get up and go to the bathroom or are wet, have somebody to help them eat. It does mean that families at home can get somebody to help them teach them how to care for, perhaps an elderly frail spouse maybe with memory loss or pain from osteoporosis. Those sorts of things we can do. We do have to engage more than just the paid healthcare system though. It has to be caring for people through the end of life. It has to be part of our families and communities. So this responsibility is really shared, I believe in the communities of our towns but also of our neighborhoods, of our buildings, the communities of our faith communities of our service groups, those sorts of things. This ought to be just part of what we do for one another, and not sort of somehow segregated and isolated.
Question: Should people take care of their parents at home?
Ira Byock: Well, to the extend possible, absolutely, people – one of the great commonalities of the human condition is that the large majority of people would rather be at home during the last part of life, not everybody. But into the 75 to 80% of people say, yeah I want to be at home, or in the home of my family or friends, I don’t want to be in some institution. And so yes, now it’s hard these days because people have to work, many couples have two jobs or three jobs between them just to make ends meet, to pay health care insurance and the like.
So we have to make provisions through insurance and through policy to make that possible, but I don’t think we will ever completely avoid the burden that caring for one another represents. I don’t want to somehow give the impression that some change in policy or insurance is going to just make this easy. It will never be easy but it doesn’t have to be nearly as hard it is today.
Question: Which culture treats its elderly well?
Ira Byock: I am not traveled that much, I think the United Kingdom does a good deal better than we do. I think Canada that are partners to the north does it somewhat better than we do. For one thing in America many times people I meet in healthcare for are worried about leaving their families with financial burdens. They want to get this over more quickly, because I don’t want to leave my family with bills to pay and go through all of our family life savings.
That’s an American source of suffering, you don’t hear that from patients in Canada. They still worry about lots of things, pain and suffering and being a burden to their family in other ways, but this notion that we are going to go through all of our wealth and in fact leave our family with debts, boy that’s a big theme that I here from patients today, and it is an American source of suffering.
Recorded on: March 21, 2008
Do we mistreat the elderly?
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A machine learning system lets visitors at a Kandinsky exhibition hear the artwork.
Have you ever heard colors?
As part of a new exhibition, the worlds of culture and technology collide, bringing sound to the colors of abstract art pioneer Wassily Kandinsky.
Kandinsky had synesthesia, where looking at colors and shapes causes some with the condition to hear associated sounds. With the help of machine learning, virtual visitors to the Sounds Like Kandinsky exhibition, a partnership project by Centre Pompidou in Paris and Google Arts & Culture, can have an aural experience of his art.
An eye for music
Kandinsky's synesthesia is thought to have heavily influenced his painting. Seeing yellow summoned up trumpets, evoking emotions like cheekiness; reds produced violins portraying restlessness; while organs representing heavenliness he associated with blues, according to the exhibition notes.
Virtual visitors are invited to take part in an experiment called Play a Kandinsky, which allows them to see and hear the world through the artist's eyes.
Kandinsky's synesthesia is thought to have heavily influenced his 1925 painting Yellow, Red, Blue.Image: Guillaume Piolle/Wikimedia Commons
In 1925, the artist's masterpiece, "Yellow, Red, Blue", broke new ground in the world of abstract art, guiding the viewer from left to right with shifting shapes and shades. Almost a century after it was painted, Google's interactive tool lets visitors click different parts of the artwork to journey through the artist's description of the colors, associated sounds and moods that inspired the work.
But Google's new toy is not the only tool developed to enhance the artistic experience.
Artist Neil Harbisson has developed an artificial way to emulate Kandinsky by turning colors into sounds. He has a rare form of color blindness and sees the world in greyscale. But a smart antenna attached to his head translates dominant colors into musical notes, creating a real-world soundtrack of what's in front of him. The invention could open up a new world for people who are color blind.
A new study suggests that private prisons hold prisoners for a longer period of time, wasting the cost savings that private prisons are supposed to provide over public ones.
- Private prisons in Mississippi tend to hold prisoners 90 days longer than public ones.
- The extra days eat up half of the expected cost savings of a private prison.
- The study leaves several open questions, such as what affect these extra days have on recidivism rates.
The United States of America, land of the free, is home to 5 percent of the world's population but 25 percent of its prisoners. The cost of having so many people in the penal system adds up to $80 billion per year, more than three times the budget for NASA. This massive system exploded in size relatively recently, with the prison population increasing by six-fold in the last four decades.
Ten percent of these prisoners are kept in private prisons, which are owned and operated for the sake of profit by contractors. In theory, these operations cost less than public prisons and jails, and states can save money by contracting them to incarcerate people. They have a long history in the United States and are used in many other countries as well.
However, despite the pervasiveness of private contractors in the American prison system, there is not much research into how well they live up to their promise to provide similar services at a lower cost to the state. The little research that is available often encounters difficulties in trying to compare the costs and benefits of facilities with vastly different operations and occasionally produces results suggesting there are few benefits to privatization.
A new study by Dr. Anita Mukherjee and published in the American Economic Journal: Economic Policy joins the debate with a robust consideration of the costs and benefits of private prisons. Its findings suggest that some private prisons keep people incarcerated longer and save less money than advertised.
The study focuses on prisons in Mississippi. Despite its comparatively high rate of incarceration, Mississippi's prison system is very similar to that of other states that also use private prisons. Demographically, its system is representative of the rest of the U.S. prison system, and its inmates are sentenced for similar amounts of time.
The state attempts to get the most out of its privatization efforts, as a 1994 law requires all contracts for private prisons in Mississippi to provide at least a 10 percent cost savings over public prisons while providing similar services. As a result, the state seeks to maximize its savings by sending prisoners to private institutions first if space if available.
While public and private prisons in Mississippi are quite similar, there are a few differences that allow for the possibility of cost savings by private operators — not the least of which is that the guards are paid 30 percent less and have fewer benefits than their publicly employed counterparts.
The results of privatization
The graph depicts the likelihood of release for public (dotted line) vs. private (solid line) prison inmates. At every level of time served, public prisoners were more likely to be released than private prisoners.Dr. Anita Mukherjee
The study relied on administrative records of the Mississippi prison system between 1996 and 2013. The data included information on prisoner demographics, the crimes committed, sentence lengths, time served, infractions while incarcerated, and prisoner relocation while in the system, including between public and private jails. For this study, the sample examined was limited to those serving between one and six years and those who served at least a quarter of their sentence. This created a primary sample of 26,563 bookings.
Analysis revealed that prisoners in private prisons were behind bars for four to seven percent longer than those in public prisons, which translates to roughly 85 to 90 extra days per prisoner. This is, in part, because those in private prison serve a greater portion of their sentences (73 percent) than those in public institutions (70 percent).
This in turn might be due to the much higher infraction rate in private prisons compared to public ones. While only 18 percent of prisoners in a public prison commit an infraction, such as disobeying a guard or possessing contraband, the number jumps to 46 percent in a private prison. Infractions can reduce the probability of early release or cause time to be added to a sentence.
It's unclear why there are so many more infractions in private prisons. Dr. Mukherjee suggests it could be the result of "harsher prison conditions in private prisons," better monitoring techniques, incentives to report more of them to the state before contract renewals, or even a lackadaisical attitude on the part of public prison employees.
What does all this cost Mississippi?
The extra time served eats 48 percent of the cost savings of keeping prisoners in a private facility. For example, it costs about $135,000 to house a prisoner in a private prison for three years and $150,000 in the public system. But longer stays in private prisons reduce the savings from $15,000 to only $7,800.
As Dr. Mukherjee remarks, this cost is also just the finance. Some things are a little harder to measure:
"There are, of course, other costs that are difficult to quantify — e.g., the cost of injustice to society (if private prison inmates systematically serve more time), the inmate's individual value of freedom, and impacts of the additional incarceration on future employment. Abrams and Rohlfs (2011) estimates a prisoner's value of freedom for 90 days at about $1,100 using experimental variation in bail setting. Mueller-Smith (2017) estimates that 90 days of marginal incarceration costs about $15,000 in reduced wages and increased reliance on welfare. If these social costs were to exceed $7,800 in the example stated, private prisons would no longer offer a bargain in terms of welfare-adjusted cost savings."
It is possible that the extra time in jail provides benefits that counter these costs, such as a reduced recidivism rate, but this proved difficult to determine. Though it was not statistically significant, there was some evidence that the added time actually increased the rate of recidivism. If that's true, then private prisons could be counterproductive.
A Harvard professor's study discovers the worst year to be alive.
- Harvard professor Michael McCormick argues the worst year to be alive was 536 AD.
- The year was terrible due to cataclysmic eruptions that blocked out the sun and the spread of the plague.
- 536 ushered in the coldest decade in thousands of years and started a century of economic devastation.
The past year has been nothing but the worst in the lives of many people around the globe. A rampaging pandemic, dangerous political instability, weather catastrophes, and a profound change in lifestyle that most have never experienced or imagined.
But was it the worst year ever?
Nope. Not even close. In the eyes of the historian and archaeologist Michael McCormick, the absolute "worst year to be alive" was 536.
Why was 536 so bad? You could certainly argue that 1918, the last year of World War I when the Spanish Flu killed up to 100 million people around the world, was a terrible year by all accounts. 1349 could also be considered on this morbid list as the year when the Black Death wiped out half of Europe, with up to 20 million dead from the plague. Most of the years of World War II could probably lay claim to the "worst year" title as well. But 536 was in a category of its own, argues the historian.
It all began with an eruption...
According to McCormick, Professor of Medieval History at Harvard University, 536 was the precursor year to one of the worst periods of human history. It featured a volcanic eruption early in the year that took place in Iceland, as established by a study of a Swiss glacier carried out by McCormick and the glaciologist Paul Mayewski from the Climate Change Institute of The University of Maine (UM) in Orono.
The ash spewed out by the volcano likely led to a fog that brought an 18-month-long stretch of daytime darkness across Europe, the Middle East, and portions of Asia. As wrote the Byzantine historian Procopius, "For the sun gave forth its light without brightness, like the moon, during the whole year." He also recounted that it looked like the sun was always in eclipse.
Cassiodorus, a Roman politician of that time, wrote that the sun had a "bluish" color, the moon had no luster, and "seasons seem to be all jumbled up together." What's even creepier, he described, "We marvel to see no shadows of our bodies at noon."
...that led to famine...
The dark days also brought a period of coldness, with summer temperatures falling by 1.5° C. to 2.5° C. This started the coldest decade in the past 2300 years, reports Science, leading to the devastation of crops and worldwide hunger.
...and the fall of an empire
In 541, the bubonic plague added considerably to the world's misery. Spreading from the Roman port of Pelusium in Egypt, the so-called Plague of Justinian caused the deaths of up to one half of the population of the eastern Roman Empire. This, in turn, sped up its eventual collapse, writes McCormick.
Between the environmental cataclysms, with massive volcanic eruptions also in 540 and 547, and the devastation brought on by the plague, Europe was in for an economic downturn for nearly all of the next century, until 640 when silver mining gave it a boost.
Was that the worst time in history?
Of course, the absolute worst time in history depends on who you were and where you lived.
Native Americans can easily point to 1520, when smallpox, brought over by the Spanish, killed millions of indigenous people. By 1600, up to 90 percent of the population of the Americas (about 55 million people) was wiped out by various European pathogens.
Like all things, the grisly title of "worst year ever" comes down to historical perspective.
A new study finds an unusual genetic difference in people over 105.
- Researchers conduct genetic analyses of 81 Italian people who are over 105 years in age.
- Five unusual genetic differences were discovered.
- The differences are implicated in the routine repair of DNA, which seems to work unusually well in these people.
The oldest living person is Kane Tanaka of Fukuoka, Japan, who just celebrated her 116th birthday. The handful of people who live to be 105 years old or older are called "semi-supercentenarians." (Supercentenarians live to the ripe old age of 110 or older.)
New research, published in the Aging, Geroscience and Longevity: A Special Issue of the journal eLife, examines the genomes of semi-supercentenarians and has discovered what may be the key to their unusually long lives: Their DNA is exceptionally good at repairing itself.
People involved in the study
Men play cards in Martina Franca, ItalyCredit: sabino.parente via Adobe Stock
The researchers recruited 81 volunteers for genetic analysis from across Italy. Some participants were semi-supercentenarians and others were supercentenarians. Researchers compared the genetic makeup of the older volunteers with those of 36 healthy people from the same areas who were 68 years old, plus or minus 5.9 years.
"Aging is a common risk factor for several chronic diseases and conditions. We chose to study the genetics of a group of people who lived beyond 105 years old and compare them with a group of younger adults from the same area in Italy, as people in this younger age group tend to avoid many age-related diseases and therefore represent the best example of healthy aging."
The authors of the study collected blood samples from both groups and conducted whole-genome sequencing. Additionally, they compared their findings with the conclusions drawn in previously published research describing the genetic makeup of 333 Italian people older than 100 years and 358 who were approximately 60 years old.
Co-first author of the new research Massimo Delledonne of the University of Verona said, "This study constitutes the first whole-genome sequencing of extreme longevity at high coverage that allowed us to look at both inherited and naturally occurring genetic changes in older people."
It's all in the genes
In the semi-supercentenarians and some supercentenarians, the researchers discovered five unusual genetic changes that were often present in two genes, COA1 and STK17A, data that was consistent with the previous research.
Most intriguing, the genetic variations appear to be linked to increased activity of the STK17A gene in some tissues, a gene involved in three critical cell repair activities: managing cells' response to DNA damage, prompting badly damaged cells to die off, and controlling the amount of dangerous reactive oxygen species in a cell. Cells unable to perform these types of repair activities are more likely to become cancerous.
The COA1 gene is involved with energy production by promoting communication between the cell nucleus and mitochondria. The researchers believe that the genetic variants they detected reduce the level of COA1 activity, which in turn reduces energy production as well as aging. (One of the leading theories of aging is that energy production produces reactive oxygen species that damage cells and promote aging.)
Finally, the researchers noted that the genetic variants they identified are also linked to increased expression of he BLVRA gene in some tissue. This gene is also involved in the elimination of dangerous reactive oxygen species.
"Our results suggest that DNA repair mechanisms and a low burden of mutations in specific genes are two central mechanisms that have protected people who have reached extreme longevity from age-related diseases."