A Disease Called Ageism

Abstract

In this issue of the journal, we have an article by W. Watson Buchanan on references to the problems of aging in eighteenth-century Scottish poetry. I am not deeply disturbed by evidences of ageism described in Buchanan's essay, and certainly would regard any notions that the poet Robert Burns had on aging as somewhat irrelevant since he died at 37. The least controversial conclusion I come to is that ageism knows no one century, nor culture, and is not likely to go away any time soon. This is because it expresses something deep within us, our own fear and uneasiness about aging, and especially the prospect of the painful concomitants of aging, disease, and disability, possibly forcing us into frightening and disturbing dependency. Nonetheless, the progress we hope to achieve is linked to the rich prospects for intergenerational or transgenerational unity and the education we hope to instill concerning the essential continuity and unity of life. To do so does depend upon our unfailing efforts to alter present-day negative imagery, stereotypes, myths, and distortions. I originally coined the term “ageism” in 1968, when, as Chairman of the District of Columbia Advisory Committee on Aging, I had been actively involved in the acquisition of public housing for older people. Vehement opposition arose against purchasing a high rise in northwest Washington, in my own neighborhood. The causes of my neighbors’ negativism were mixed, but in no small measure a function of ageism. I am frequently asked if I do not believe there have been improvements since that time, and indeed I do. The extraordinary efforts of the late Congressman Claude Pepper led to the passage and enforcement of the Age Discrimination and Employment Act, including the virtual ending of mandated retirement. Some improvements in the health care of older persons have occurred. And there is greater public sensitivity toward older people, and perhaps less use of such heinous epithets as “geezer,” “gork,” and “crock.” But we do see a new ageism. We hear a rising chorus of voices further criticizing the aged, suggesting that they have too many advantages, and that their advantages have come at the expense of children. Unfortunately, these views come from powerful quarters, from politicians, scientists, and philosophers. Fortunately, the public at large does not accept these notions. All national polls and surveys reveal just the opposite, that persons of all ages wish to see older people keep their entitlements to Social Security and Medicare, or even have them expanded. There is no evidence to support the idea that there is widespread intergenerational conflict. Although we may know the disease of ageism in its broad outline, we must be constantly attentive to current manifestations. This includes economic forms of ageism in contemporary medical practice. Since Medicare counts, on average, for 21% of the income of physicians, the Maximal Allowable Actual Charge of Medicare (the MAAC) and the lower benefit payment compared to private insurance understandably causes physicians to watch their case-mix carefully. So long as 20% of older people living alone are below the poverty line, they are unattractive to physicians. We cannot totally blame physicians who must meet their practice costs and, American style, seek to meet their own economic requirements, and so avoid older patients. Indeed, we must admire those physicians who have shown a particular interest in older persons, the majority accepting patients on Medicare assignment. We still recognize another aspect of “medical ageism,” the still modest effort of most of our 127 medical schools to educate their students responsively with respect to gerontology and geriatrics. Once again, we recognize an economic problem, the lack of resources to train and secure teachers. In March of 1988, a cover article of The New Republic criticized our society for “pampering our affluent and elderly population,” the “greedy geezers.” Apparently, the fact that some older persons have managed to enjoy a decent, leisurely retirement, after a lifetime of work, was disconcerting to the author, who failed to give as much emphasis to the fact that only 6% of people over 65 have incomes in excess of $50,000, and that older people are the poorest of all adults. Along with children, older widows endure 20% poverty rates. If we diagnose the social disease of ageism correctly and examine its current context and manifestations, our next question as physicians must be “What is the treatment?” Here I would quote Georges Bernanos, who wrote, “The worst, the most corrupting lies are problems poorly stated.” We must begin by systematically analyzing the many myths and distortions about aging. Too much is attributed to age that is actually due to disease, disability, social adversity, personality, educational level, alcoholism, life-style, or the environment. What else must we do? We must be ready to write letters to the editor, participate in radio phone-ins, or write scholarly articles, to offset the growing numbers of false articles building a myth that all older people are affluent. Here the fine work of the Commonwealth Fund Commission on Elderly People Living Alone should be cited. “Aging Alone: Profiles and Projections” describes widows as the primary victims of elderly poverty. Pessimists support the myth that health care for our older population is unaffordable. But Canada, our northern neighbor, is able to provide access to total health care for all its people, and does so at 2% less of its yearly GNP per year than the United States. Sweden, East and West Germany, and others already have a higher percentage of older people than does the United States, and they are surviving quite well. Specifically, Sweden has the highest proportion of people over 65 (17%) and people over 80 (3.5%). Yet, during the recent Swedish elections, the Conservatives as well as the Social Democrats came out for stronger financial support of older people. Parties are in agreement that Sweden is not falling apart; in fact, its economic situation is quite favorable. The People's Republic of China already has 80 million people over 60, and the situation will become even more dramatic for China, which will have 240 million people over 60 in about the year 2045. Yes, China is a very poor country, but its economic position is not due to its elderly population. The concept that nations will be bankrupted by growing older populations is not accurate. What about the myth that the Social Security System is bankrupt, and that when young people reach age 65, they will not receive Social Security benefits? Social Security is not bankrupt; rather, trust funds are becoming enormous. They will be in the vicinity of a trillion dollars at the turn of the century and 12 trillion dollars when all the Baby Boomers are 65 years of age and over. The dependency ratio is also misunderstood. Not everything is given to the elderly. It is true that there is an increasing number of retirees compared to nonretirees, but if one looks at the total dependency ratio; that is, people under 18 and people 64 and above, there has been a steady decline in the total dependency ratio since the year 1900, and this decline will continue to the year 2050. This is because of the low birth rate—just below zero population growth. Income transfers do not simply go from young to old through the public means of Social Security, Medicare, and related entitlements. Social Security itself is a multi-generational, lifelong protection system. Benefits are not limited to retirees; in fact, 3 million children receive Social Security benefits. A more sophisticated question is related to the actual cost of old compared to young. One must look to all sources. When one looks only at federal expenditures, the old certainly receive more than the young. In our system of government, however, we desire protection from the authority of the centralized state. Education, the great expenditure for the young, is not supported by the federal sector, but rather on a community basis through property taxes. If the New Ageists would look at all sources, they would recognize that a huge amount of money goes to children, as is wholly appropriate. There is no doubt that the condition of children as a group has deteriorated, but older people have not caused this deteriorating condition, nor will we improve the welfare of children by stripping from the elderly what they have achieved. We need to support intergenerational programs that build alliances between advocates for the children and advocates for the elderly. One answer to the exploitation of intergenerational conflict has come with the founding of Generations United, which now includes the Child Welfare League of America and the National Council on Aging, as well as most mainstream organizations that have been advocacy groups for children and old people. The myth of the high cost of dying needs to be dispelled. Studies show that the aged do not really contribute to rising health costs as much as technology does, and technology, such as heart transplants, are rarely used in older people. Only 6% of U.S. Medicare beneficiaries in their last illness utilize in excess of $15,000 in expenses (that is, perhaps, 30 days in a hospital). Our government does need to create an expanded National Center of Health Services Technology to evaluate medical technological innovations, monitor the appropriateness of their use, and disseminate information to help improve their applications. Another intervention against ageism is the recognition that older people themselves constitute a market. There is lot of “gold in geriatrics” as the Wall Street Journal once wrote. But capitalism is a connection between producers and consumers. Thus, the so-called high cost of health and social services produces jobs and consumption. We speak of the rising cost of health, but looking at it in another way, the health-care enterprise is the second largest producer of jobs. We should not forget that it does contribute to the GNP. This is true of pension funds as well, which constitute the largest source of capital formation in our country, owning half of American stocks. Another major intervention against ageism would be to mobilize the productive capabilities and contributions of older people. Society would be wise to develop incentives for part-time employment, entrepreneurism, and more extensive participation of older persons as volunteers. We must also make heavy investments in biomedical and behavioral research; new knowledge and its application make up the ultimate cost-containment, the ultimate disease-prevention, and the ultimate service. When we eliminate Alzheimer's disease, the polio of geriatrics, we will empty half of our country's nursing-home beds. Spending a few dollars now will dramatically affect the image of senility and debility as inevitable in old age. The struggle against ageism—even the New Ageism—like liberty, requires constant vigilance, but there are signs of success. The more critical issues in our society are social class and race. Ageism is a primitive disease, and, unfortunately, our own fears about aging are so deep that ageism could lead to the possibilities of rationing and denial of care and income. Robert Burns, the great Scottish bard, died prematurely at 37 and was a great voice of the people. It is possible, perhaps likely, that he would have given us thoughtful insights into the later stages of life, middle age, and old age, had he been privileged to enjoy them.

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