‘Rage against the dying of the light’ in the way we treat elderly people

The alienation of elderly people from social life is abundantly evident in the impact of coronavirus on society as it exploits the vulnerable and defenceless.

Grave men, near death, who see with blinding sight ,Blind eyes could blaze like meteors and be gay, Rage, rage against the dying of the light.

And you, my father, there on the sad height, Curse, bless, me now with your fierce tears, I pray. Do not go gentle into that good night.
Rage, rage against the dying of the light. (Dylan Thomas, 1914-1953)

Dylan Thomas’s call to fight and not give up about ageing is needed at this time of great uncertainty.

We too should rage and anguish. Rage against those who discount the lives of others, less strong. Anger at the neglect of our impaired and elderly citizens.

Opposition to lockdowns

Pragmatic public health measures are being widely flouted in many western countries – the US and UK and shamefully in our own. There are outbreaks of mob behaviour, often violent and threatening. Behaviour that is anonymous and cowardly. Lost in the crowd; values and behaviour are subsumed in the mob.

For some, their behaviour expresses their oppression, their aggrievement and anger at their predicament; but not for the hedonists demanding pleasure, entertainment and intoxication. Fear and feelings of outrage are exploited by cheer leaders which drives much of the opposition to sensible public health measures.

These reactions are capped by the statements of a former judge of the British Supreme Court, Lord Sumption. On the BBC and in the Times and Spectator of London he railed against lockdowns and other restrictions. He condemned lockdowns as a “wicked infringement of our liberty” and dismissed the notion that the NHS was at risk of being overrun.

He said the public health rationale is flawed as, “…this virus attacks people with severe existing vulnerabilities. Nearly nine-tenths of the dead were aged 65 or over and likely to have been retired. The number of working days lost through non-mortal illness are fewer by far than days lost through the lockdowns.” For Lord Sumption and his ilk, individual rights, freedoms and economics trump community health.

These thoughts are not popular, but they can too easily gain momentum, even in Australia. They do pose an existential question for us. How do we value the lives of ageing people or people with multiple conditions and disabilities? Bear in mind that a large proportion of those who attend for health care have multiple conditions – which span mental and physical illnesses, impairments and disabilities – which includes all age groups.

Ageing

Chronological age is not a reliable predictor of function or biological ageing. Age-related impairments, diseases and disabilities are conditioned by social circumstances, exposures and medical conditions. Not everyone who looks old, is old. Conversely not all of advanced age are dysfunctional and most are able to live worthwhile lives, as attested by many contributors to Pearls and Irritations.

It happens there is a group of old people – who are congregated in predominantly isolated and private institutions – nursing homes and aged care housing – beyond public oversight. A perfect nidus for the transmission of infection, manifest disease and death.

The coronavirus and society

The social impact of the coronavirus has exposed how rich travellers first carried the virus into populations which then rampaged through vulnerable groups, the already impaired and frail and the poor in many countries.

The economist, Jayati Goshi said of India’s response, “…(it) was never about lives versus livelihoods: it was, and continues to be about lives versus lives, with some lives being cheaper than others. The disease entered India through those who have travelled abroad – top 2% of the population. The poor have had to suffer disproportionately because of it – and now, increasingly, are being blamed for its spread.” (Guardian, 7th August) And there are flow on effects in all countries. In Pakistan 40 million children will miss their polio vaccination – and in many countries community health services are seriously eroded.

These societal impacts are captured in Camus’s – The Plague, “the pestilence is at once blight and revelation. It brings the hidden truth of a corrupt world to the surface”, quoted by Sir Michael Marmot in a recent issue of Epidemiology and Community Health.

Shame

As young locum in general practice I was given a list of patients to visit for their third-daily injection of a mercurial diuretic for heart failure; modern treatment makes this practice unnecessary. Entering the barren courtyard of the aged home there were no signs of life; windows blanked out with drawn blinds. Inside, darkness, and the cloying odour of disease. Followed by the struggle with untidy records to assess the elderly person’s condition.4 I walked away ashamed to think of the hundreds of doctors entering aged care facilities every day: What do they think? What is their response to the conditions of care?

Senator Fierranti-Wells, former opposition spokesperson for aged care, is right to submit to the Royal Commission into Aged Care Quality and Safety that, “one of the problems with aged care is the lack of willingness of medical practitioners to visit nursing homes.” There is shared guilt and shame at the failures over many years in our neglect of the conditions of the infirm elderly in these settings.

Geriatric care

We should admire those who work in aged care facilities for the thankless and intimate tasks expected of them and how they try to overcome the barriers to the best care they know. Like the people they care for, they are stigmatised – by low status and remuneration. And the institutions in which they work are shunned and ignored. Which leads to deficits in skills, technology, ability to manage infectious disease and to protect those in their charge.

Geriatric medicine can make seminal contributions to the way ageing people are cared for. The first chair in geriatrics at the University of New South Wales was established in community medicine which meant teaching and research could be based on ageing in the community. In subsequent years, the status of a teaching hospital appointment dragged geriatrics as a discipline back to the hospital environment. A sad loss to the community and the aged.

There have been gains however. The appointment of geriatricians to public hospitals has been a countervailing movement to super-specialisation. Expertise in general medicine is important when caring for patients with a mix of serious problems and, as complexity is bread-and-butter work for geriatricians, they have been able to fill some of the gaps left by specialist medicine.

In parallel with the changes in hospital medical staffing, patients are getting older. Ken Hillman, Professor of Intensive Care, describes how in the early 90s Liverpool Hospital had six ICU beds devoted mainly to trauma and post-operative patients; now, the hospital has sixty ICU beds occupied largely by elderly patients with multisystem failures. He wrote in A Good Life in 2017, “I now work in a unit with 40 beds at a cost of at least $4000 per patient per day. But, it’s not just the number of intensive care beds that has changed; it’s the nature of the patients we treat. Most of them are over the age of 60. Many are in their 80s or 90s. And many of those are in the last few days or weeks of their lives.”

Simone de Beauvoir’s solution to old age

“There is only one solution if old age is not to be an absurd parody of our former life, and that is to go on pursuing ends that give our existence meaning – devotion to individuals, groups or to causes, social, political, intellectual or creative work. In spite of the moralists’ opinion to the contrary, in old age we should wish still to have passion strong enough to prevent us turning in upon ourselves. One’s life has value so long as one attributes value to the life of others, by means of love, friendship, indignation, compassion. When this is so, then there are still valid reasons for activity or speech.

But these possibilities are granted only to a handful of privileged people: it is in the last years of life that the gap between them and the vast majority of mankind becomes deepest and most obvious. When we set these two old ages side-by-side we can answer the question ….: what are the inescapable factors in the individual’s decline? And to what degree is society responsible for them?”

The policies and institutions which fashion the care of our aged and infirm citizens need drastic reform, but the root of the problem is more profound, for, as Simone de Beauvoir attests, the value we attach to the lives of others lies deep in our culture, attitudes and social relationships.

That is the real challenge for the Royal Commission into Aged Care and for all of us.

Grave men, near death, who see with blinding sight,Blind eyes could blaze like meteors and be gay, Rage, rage against the dying of the light.

And you, my father, there on the sad height, Curse, bless, me now with your fierce tears, I pray. Do not go gentle into that good night.
Rage, rage against the dying of the light.

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Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.

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