So far away

My favorite Boomer singer-songwriter Carole King (age 78!) captured the zeitgeist of our COVID-19 distancing era with her wistful reworking of her classic 1971 song, "So far away / Everybody has to stay in one place anymore / It would be so fine to see your face at my door / Doesn’t help to know / You’re just time away…" 

“One more song about movin' along the highway/ Can't say much of anything that's new” reminded me that coronavirus infects people regardless of age, health status, race/ethnicity, or income/wealth.  Yet it has a disproportionate impact of severity on older people and certain groups due to structural ageism/ableism and other -isms that drive social determinants of health—housing, income/wealth, employment, education (including English language/digital fluency), immigration, access to health systems—and make it challenging for people to protect themselves.  I protect myself, and you.

  

“The people who get the most severely sick from COVID-19 will sometimes be unpredictable, but in many cases, they will not. They will be the same people who get sick from most every other cause. Cytokines like IL-6 can be elevated by a single night of bad sleep. Over the course of a lifetime, the effects of daily and hourly stressors accumulate. Ultimately, people who are unable to take time off of work when sick—or who don’t have a comfortable and quiet home, or who lack access to good food and clean air—are likely to bear the burden of severe disease.”—James Hamblin, MD, “Why some people get sicker than others: COVID-19 is proving to be a disease of the immune system. This could, in theory, be controlled,” The Atlantic, Apr. 21, 2020

According to the American Geriatrics Society, more than 30% of COVID-19 cases in the U.S. involve older people (age 65+), who also account for 45% of hospitalizations, 53% of intensive care unit (ICU) admissions, and 80% of deaths.  To what extent are these outcomes related to ageism in overlooking unique COVID-19 symptoms presented by older adults who are not provided option of safely testing at home, and provider bias in how older lives are valued when faced with scarce resources?

May you live until 120+! While older people have higher risk of mortality after coronavirus infection, there has been good news coverage of the resilience of centenarians (most identified as residing in care facilities, previously invisible to the public) who survived COVID-19:

·       107-year-old Cornelia Ras, Netherlands nursing home resident, takes no medicines, loves sitting in her balcony on sunny days and has good workout routine (“still walks well and gets down on her knees every night to thank the Lord”) 

·       106-year-old Connie Titchen, Brit credited being “physically active and very independent” 

·       104-year-old Vera Mueller, Minnesota assisted living resident, credited “faith and family” 

·       104-year-old Bill Lapschies, Oregon Veterans Home resident, said “sit out here and you can get rid of anything”

·       103-year-old Ada Zanusso, Italy “old people’s home” resident with no chronic illness, credited “courage and strength, faith” 

Aw, nothing like the lived experience of centenarians to inform one’s perspective on the current COVID-19 pandemic:

"Over 107 years I've faced other problems. Living is a problem. You do what you need to do to handle the problem that's in front of you at this moment. And this moment it's a virus that unfortunately we don't understand too much about … together, we’re 207, the years we can look forward to, whatever they be, whether they be many or few, and even if they're just days, to look forward to them. And then hope for another one."—107-year-old Joe Newman in conversation with his 100-year-old fiancé Anita Sampson, both residents in senior community in Sarasota, Florida, “For centenarian survivor of 1918 flu pandemic, coronavirus is just another'problem',” NPR Hunker Down Diaries, Apr. 15, 2020 

     

“Our lives, our dreams, our productivity don’t end when we turn 65, an age that society decided was ‘old enough.’ Senior citizens can be productive and contribute to the world, bringing to it their added dimension of age and experience. I think no limit should be set on when a person’s life is no longer valuable.

I’m 90 and I’m waiting for the quarantine to end. As long as I’m still creative and surrounded by the love of family and friends, as long as I still enjoy life, nobody has the right to write me off.” –Varda Yoran, “Just because I’m 90 doesn’t mean I’m ready to die – or disposable,” HuffPost, Apr. 29, 2020 

Last month, the U.S. Department of Health and Human Services’ Office of Civil Rights issued guidance saying that states, hospitals and doctors cannot put older people/people with disabilities at the back of the line for care.  Alarmingly, but not surprisingly, California Governor Newsom’s Administration advised hospitals to prioritize care for young people, and people with the greatest likelihood of surviving with treatment over those with serious chronic conditions that limit their life expectancy, during COVID-19 outbreak, and then retracted in response to protests. #NoBodyIsDisposable. 

“While we’re sheltering in place, it will save the human race

The economy might stink, while our stocks have gone extinct”

—Abby Goldfarb, Corona virus (Grease Lightning) 

The evolving COVID-19 pandemic seemed to bring confusion each day: face mask recommendation, reusable shopping bag ban, “unusual” symptoms, possible “cures,” politicians backtracking and not really doing much to strengthen the safety net to address people’s real fears about survival (some taking on risks of public-facing “essential work” to pay bills) and desires to “reopen the economy” and get back to “making a living.”  Some called for herd immunity, which would be most devastating to older people/vulnerable groups and overwhelm hospitals, instead of waiting for scientists to develop a vaccine.  81-year-old Mayor Carolyn Goodman callously offered to reopen Las Vegas as a “control group” to measure effects of lifting restrictions.  Calls that “we are all in this together” were matched with deepening political polarization and intensified economic and social inequities resulting from flawed policies. 

“From a distance,

Trump’s still an idiot, motivated by pure greed

We need someone smart, Someone science-based

Let Tony Fauci lead

Now you’re watching us from a distance…

From a distance that’s where we’ve got to stay

If we want to make it through…”

From a (social) distance song parody by Emma’s Revolution (Apr. 7, 2020)

So far away from reopening as SF issued extension of “shelter-in-place” order (32 pages!) from May 3 to May 31.  Just need to add digit “1” on old SF DPH’s stay home longer poster.  Extension allows opening of outdoor businesses like plant nurseries, but why not reopen SF Botanical Garden for staycation? As a good citizen, I stay tuned to SF COVID-19 updates on Monday, Wednesday and Friday—listening to City officials report progress on activities/plead for public cooperation to slow the spread of transmission (shelter-in-place, distancing, face covering, disinfecting environment), testing, contact tracing, and treatment (dedicated hospital beds, ventilators). 

After CDC recommended cloth face masks (not medical N95 masks in short supply) for the public, SF DPH issued order requiring public age 12+ to wear face coverings except if one has “trouble breathing or is unconscious, incapacitated, or otherwise unable to remove the Face Covering without assistance.” Or what many Chinese were already doing because who knows if one is infected and asymptomatic? Yet, cloth face masks may not be a safe option for some black and Latinx people due to racial profiling associating handkerchief/bandana face coverings with violent gangs. I was disappointed to see people continue to smoke in public, perhaps trying to fit under “trouble breathing” exception to wearing face covering?

“The global lockdowns and forced hibernations should not just be seen as measures of imposed isolation. The Pandemic State has done much to kill off that delicate creature of solitude, the routine of tranquil space essential to life. Privacy…vanishes in spaces crowded and crammed, even with your intimates.

In the context of health and a raging pandemic,…using a disease to affect vulnerability, thereby keeping a tormented partner or relation in that space. The range of human manipulations in that regard are legend and endless…

The impediments for sufferers to access services has also seen social workers and activists turn to more virtual and online methods of communication, a point that can only ever be half-satisfying at best…”--Binoy Kampmark, Hell is other people: Pandemic lifestyles and domestic violence, Counterpunch, Apr. 17, 2020

Reports of domestic violence have increased since stay at home orders, with victims stuck in proximity to perpetrators, restricting access to counseling, shelter and other community resources.  But South Africa reported a decline in domestic violence, thanks to its lockdown that included banning alcohol and tobacco sales (though latter recently lifted). 

In SF, people experiencing domestic violence now can silently text 911 for help, and the Census is online for the first time.  For people in the digital divide such as many older adults who lack internet access or digital literacy skills, Census 2020 can be completed by phone and mailed questionnaire. 

Advocates took action to urge CMS to expand telehealth to include Medicare reimbursement for psychotherapy provided via audio-only devices (e.g. landlines), particularly for Medicare beneficiaries experiencing adverse effects of distancing who may not have access to audio-visual technology yet need to connect with mental health providers like clinical social workers.  Today, CMS announced pay parity for audio-only telehealth visits for psychotherapy, retroactive to March 1, 2020. 

“No, Papa. It is not because the CDC asked me to stay.

I want to stay. I need to help flatten the curve,

It is the greatest curve we’ve had to smush, Papa.

But I am not alone

We are together for seder on the Zoom…”

--Marnina Schon, Far from the home I Zoom parody of Fiddler on the Roof’s Far from the home I love (Apr. 13, 2020)

SF DPH released its COVID-19 data tracker online reporting demographic data (gender, age group, race/ethnicity, zip code).  Of 18,815 test results to date, 1,499 positive cases (60% men) and 25 deaths (96% age 60+; 13 Asian, 6 White, 3 Black).  While this transparency is welcome, SF DPH will not disclose SRO hotels with COVID-19 cases as privacy concerns seem to outweigh protecting other residents. (The City also failed to follow through on providing hotel rooms for quarantine; instead, it provided a COVID+ SRO resident age 80+ with a commode as alternative to using shared bathroom, and expected this monolingual Chinese resident to communicate in English via email to SF DPH staff!)  

Instead, non-profit organizations have made disclosures, alerting the media to report 24 COVID-19 cases in 52-unit Casa Quezada SRO hotel in Mission District, and demanding that DPH begin widespread testing on all people living in SROs, people living on the streets and in shelters (93 COVID-19 cases at Multi-Service Center South),  people with underlying health conditions, formerly homeless people and all essential service workers --notably, this list did not specify any age groups, but rightly focuses on context. 

Stay home, save lives does not apply at congregate settings.  At least 40% of COVID-19 deaths in California came from “eldercare homes.”  Outbreaks continued at nursing homes (67 COVID-19 cases, 4 dead at for-profit, CMS rated 4-star Central Gardens Convalescent Hospital in SF), where understaffing and lack of PPE contribute to inability to control infectious outbreaks.  At for-profit, CMS rated 2-star Magnolia Rehabilitation and Nursing Center in Riverside, 84 residents were evacuated after staff failed to show up (for reasons not disclosed, though 34 residents and 5 staff were infected with coronavirus, so prudent to quarantine if exposed).   

For each COVID-19 outbreak in a nursing home, I wish reporters would identify ownership type; based on CMS Nursing Home Compare lookups, troubled nursing homes are for-profit with wide-ranging ratings.  This calls for a re-evaluation of for-profit nursing home industry that make up 70% of nursing homes.  Yet, nursing home operators had the gall to ask Governor Newsom for near-complete immunity from administrative, criminal, and civil liability during COVID-19 pandemic. 

Last month’s draconian lockdown of nursing homes didn’t prevent transmission from asymptomatic staff, and the situation became so dire that Los Angeles County Public Health Director, Barbara Ferrer, PhD (Social Welfare), advised families to consider pulling residents from nursing homes over coronavirus if families are able to provide care at home now that so many people are working from home; Michael Wasserman, MD and California Association of Long-Term Care (LTC) Medicine President, estimated that 10%-20% of nursing home residents could be cared for by their families at home.  Even before last month’s stay at home order and nursing home lockdown, concerned physicians advised, “If you have parents/grandparents in a nursing home, you should consider moving them home for now.” 

Since the early 1990s, self-described nursing home abolitionist and geriatrician Dr. Bill Thomas has advocated for the Eden Alternative to transform the hospital-like environments of nursing homes to be more home-like “human habitats.”  Perhaps staff could live in facilities like self-isolating families? Maybe board and care homes that SF recently funded to prevent closures? 

Kokua Council held its inaugural Zoom meeting for an update with Hawaii LTC Ombudsman John McDermott, who wanted to focus on LTC beds in the community—assisted living, adult residential care home (ARCH), Community Care Foster Family Homes (CCFFH)—because Hawaii has 8,397 of them, in contrast to 4,492 nursing home beds that get more media attention.  He shared that staff from Community Ties of America (CTA) continue annual inspections of CCFFH, but now CTA staff will no longer remove shoes before entering a home! CTA justified this change in practice to protect both staff per OSHA and people in CCFFH, a business like a nursing home where staff do not remove shoes before entering (and disposable shoe coverings like PPE are in short supply).  CCFFH objected to this cultural insensitivity. Could CTA staff wipe down heels of shoes or bring a change of clean footwear for use exclusively inside home (as in Chinese custom to switch to indoor footwear)? 

In the past, I associated National Healthcare Decisions Day (NHDD) with the day after April 15 tax filings due date.  Because of the three-month extension on tax filings this year, almost forgot about NHDD though it carries greater importance during this risky age of coronavirus.  UCSF launched Be Prepared: Take Control campaign to help people make plans in the event of illness.  The goal of the campaign is to inspire people to take three actionable steps: 1) make a hospital go bag, 2) choose a medical decision maker, and document in Advance Health Care Directive (AHCD), and 3) talk to your families about your health care wishes.

SF has flattened the curve for now at least, but the focus on COVID-19 means people are delaying care or other health concerns that could lead to complications, as telehealth care is limited, with emergency rooms reporting drop in heart attacks and strokes. 

Nature (while physical distancing from people) is essential to counter computer fatigue, more so since I’ve been working remotely from home connected to my computer all day – even phone calls are made via my computer.  I joined Senior Outreach Society (SOS), brainchild of 70-year-old SF Board of Supervisors President Norman Yee, to make wellness check-in calls to senior voters in SF District 7 via CallHub, enduring annoying music played between calls.

Unsurprisingly, SF residents responded to “shelter in place” order by heading to enjoy the great outdoors, as infamously reported by CNN.  After initially defending SF residents as complying, SF Mayor then threatened to close public parks if people continued to defy public health orders for distancing.  Instead of overbroad policies to close parks, gardens and beaches, other protective measures like enforcing physical distancing through timed entry and capacity limits (as done at Trader Joe's) would enable balancing the benefits and risks of nature healing and coronavirus infection. 

Not only do we face the challenge of finding out who are asymptomatic (aka “Achilles heel” of public health interventions to control COVID-19), but doctors say old people with COVID-19 show “unusual symptoms” like changes in usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain and the loss of smell and taste.  Few were included in CDC’s updated list of COVID-19 symptoms, which now include chills, repeated shaking with chills, muscle pain, headache, sore throat, and loss of taste or smell—in addition to the original three listed symptoms of fever, dry cough and shortness of breath.  Journal of American Geriatrics Society reported that older people, especially if frail with multiple chronic conditions, may not have fever, cough, chest discomfort, or sputum production, but may present with delirium, elevated respiratory rate or heart rate.   

When will SF adopt FDA-approved saliva testing to expand testing capacity to include asymptomatic carriers? The saliva test process of spitting in vial at home, then sending for lab processing appears much safer and accessible than having older people leave homes to test sites, furthering their risk and dwindling limited supply of nasal swabs and PPE for health care workers. 

Hong Kong was an early adopter of saliva testing and behavioral interventions, described in a study published in The Lancet this month, such as face covering (even by protestors and HK Chief Executive Carrie Lam during public speeches!), physical distancing, isolating people who tested positive, and quarantining close contacts identified through contact tracing.  Much of this protocol had been followed during 2003 SARS epidemic, a memory seared in the minds of Hong Kongers.  As a result, restaurant dining remained open because these measures were enforced to reduce transmission.  During UCSF COVID-19 Town Hall meeting last week, UCSF Asian Health Institute Director Diana Lau opined that many Americans view interventions taken in Hong Kong as infringing on individual civil liberties, and UCSF infectious disease specialist Dr. Peter Chin-Hong favored saliva test but speculated Americans have a cultural bias against spitting.
I also wonder whether Hong Kong’s Confucian culture that reveres old age, family, collectivism, adaptability, long-term orientation and restraint can be credited for its impressive stats: HK has population of 7.5 million, 4 COVID-19 deaths versus SF population of 883K and 22 COVID-19 deaths, overall U.S. is worse…perhaps matching the hurtful rhetoric of vocal Americans who view deaths among older people as acceptable collateral damage so others can get on with life and restart the economy? 

Joined Caring Across Generations for an afternoon of #CareForAll consciousness raising and, what Bobbie Sackman of NYCaring Majority called, organizing to build a “feminist caring economy.”  Host Alicia Garza of National Domestic Workers Alliance (NDWA) reminded us that care is a collective responsibility that requires a collective solution, a caring majority to build a culture of care across communities and generations.  Participants called for paid family leave, universal health care, livable wages, hazard pay, immigrants’ access to supports…NDWA Executive Director Ai-jen Poo called for universal family care. 

According to the NYTimes, 1 in 3 jobs held by women (mostly nonwhite) have been designated as “essential”—mostly underpaid, undervalued—labor that takes care of people most in need and “holds everything together.”  In this COVID-19 pandemic, essential workers are mostly women, including 78% of social workers, 77% of health care, and 53% of critical retail. Notably, women make up nearly 90% of nurses and nursing assistants working the frontlines doing essential work requiring in-person interaction, and 73% of health care workers who have been infected. 

We Can Do Better: How Our Broken Long-Term Care System Undermines Care calls for equitable investment in direct care workforce to meet consumers’ needs – a failing of our system more pronounced during COVID-19 pandemic.

This is not the opening of The Brady Bunch, but lunch bunch with Lynn Mahoney, a social historian specializing in women’s rights and whiteness who made history last year when she became first female President of SFSU (120 years after its founding)! Due to COVID-19 distancing measures, her March 18 investiture ceremony as 14^th SFSU President was canceled.  However, I was one of 50 selected for free delivered lunch (SF recently capped third-party delivery app fees at 15%) and Zoom meeting with Boomer President Mahoney this week.  I’m old school in my preference for in-person meetings, and the only student who didn’t bring my own computer to class (though I used SFSU computer provided in research classes), so surprised to hear students complain about transition to zoom instruction.  I have managed computer screen fatigue by turning off my video and listening to zoom classes as if they were podcasts, freeing up my eyes and allowing me to move around, occasionally contributing to chat box and unmuting to add my two cents. 

As expected, students asked about getting refunds because campus closure prevented use of library book loaning, wellness center, student org funds, etc. (Prior to lunch date, class action already filed against California State University system.)  SFSU President shared that she was always so busy working her way (starting at Jewish bakery!) through school that she never participated in campus clubs, and then she replied no refunds because tuition collected doesn't even cover actual cost.  With shelter-in-place orders, she declared now is the best time to remain in school even if it’s online.  (She did not entertain like NYU Tisch School of the Arts Dean Allyson Green who said no refund to performing arts students, and then turned to dancing to “Losing my religion”, which she explained help her “get going again, even in the darkest moments.”) 

I may be in school as long as it takes me to complete my culminating experience, which I had to start over again because I could no longer conduct field interviews at nursing homes as planned in my original research.  Since this COVID-19 pandemic, I have been conducting research for my new project, Creating Age-Friendly Social Work Education, based on World Health Organization's Actively Ageing framework incorporating strengths-based, person-centered and life course perspectives.

To get out of my SF bubble, I continued my free online learning spree – sometimes by myself and other times converging with shut-ins from all over the world! 

Gerontological Society of America (GSA) made Ageism First Aid online course freely accessible through July 1, 2020! (Usual cost for members $20, non-members $30.)  This course’s objective is to disrupt common negative misconceptions/myths about aging by replacing them with facts that should be common knowledge—much needed during this age of coronavirus!  Some age-friendly affirmations:

·       On our aging process: Throughout our lives, when our interests and activities change, some of our abilities may be lost. As adults, most losses in abilities happen when our interests and activities change.  Use it or lose it!

·       Mental and emotional development can continue our entire life: Older people also develop the ability to manage conflicting emotions better, and thus more likely to continue on with daily life in situations that would have disrupted their life when they were younger.  Been there, done that!

·       At any age, our minds make connections to our stored memories: An older mind holds more stored memories, and thus may require more time to make connections between the stored memories and the new information. In most cases, having more experience and knowledge makes up for the extra time it may take for older people to process new information.

·       Hearing loss is not a normal part of the aging process:  Hearing loss is not common among older people in non-industrialized countries or traditional indigenous communities.  In the United States, many older people have hearing loss from damage that happened to their ears when they were much younger, before simple hearing protection was available to everyone. The unnaturally loud sounds of our industrialized modern society from blasting music, gunfire, machinery, hair dryers, etc. caused the initial damage that progresses slowly.

·       Words matter:  To avoid the negative impressions associated with the word old (“useless, inferior, out of date” or “being put/given/thrown away”), simply add an “er” and use the word older. For most of our lives, getting older is positive—as we look forward to becoming more independent.  

·       Based on research about how people age 50+ in the United States feel about aging labels, nouns person and people are preferred over the nouns adult or adults. The most positive labels to use are older people, older persons, mature adults, or number-plus labels such as 50+ adults.

·       “Helping” Behaviors: Helping an older person or a person with a disability without invitation can stigmatize people and be insulting (suggesting that you do not believe they can do the task on their own, despite your good intentions). Instead of helping without an invitation, state “let me know if I can be of assistance” or “let me know if I can lend a hand” before they start on the task. Avoid using words “help” and “need” in your statements. This approach lets the client know you are available without suggesting they are not able to do the task on their own and are less likely to be offensive.

What about reclaiming the power of old, while still embracing older?  I thought about Cat Stevens’ Father & Son lyrics, “Look at me, I am old, but I’m happy,” which David Scott @ the Kiffness turned into “Look at me, my beer is cold, and I’m happy.”  (All the funnier because they’re in lockdown with alcohol sales ban under South African President Cyril Ramaphosa of elbow greeting and mask wearing fame.)   

In this month’s Reframing the Response to COVID-19: Applying Reframed Language to Counteract Ageism, FrameWorks Institute VP for Research Interpretation Moira O’Neil objected to “vulnerability” frame because it creates distance: us (sacrificing to protect) v. them (othering/stigmatizing vulnerable older people).  Her tips for framing a society that supports older people:

·       Balance urgency and efficiency, by bringing solution and explaining: “Because older people are disproportionately impacted by the disease, states are planning community actions to reduce exposures to the virus.” 

·       Careful about positioning groups, by focusing on interconnection/shared responsibility as source of strength and universalism: “This virus is highly contagious and people could be spreading it without realizing.  When we all stay home today, we see fewer new cases tomorrow. By keeping our physical distance, we slow the spread.  This protects people in our communities who are most at risk and the availability of the lifesaving health care we all depend on.”

·       Explanation=power, by showing how actions can address problem: “Under stressful conditions, health care providers are likely to make snap decisions about people solely based on their age that will determine the quality of care they receive.  We need to make sure our standards of care do not discriminate on the basis of age.”

Finally, some age-friendly developments during COVID-19 pandemic:

·       Car-free “slow streets” for distancing on narrow or crowded sidewalks in parts of Chinatown, Tenderloin, Twin Peaks and Golden Gate Park’s JFK Drive  -- especially great for users of wheelchairs and walkers!

·       SF MTA Essential Trip Card subsidizes 2-3 roundtrips by taxi per month for age 65+ and people with disabilities who pay 20% of the cost of a regular taxi ride fare for essential trips to grocery or medical visit (but what was SF MTA thinking when it increased Muni fares, effective July?! Objection!)

·       California Governor’s initiatives to support older Californians via Restaurants Deliver Home Meals for Seniors (who are not eligible for other nutrition programs); Social Bridging Project (phone check-in); and Friendship Line California (1-888-670-1360)

·       Age-friendly health system 

·       Being resourceful like Shirley Serban’s “Cut My Hair That Way” (parody of Backstreet Boys’ I Want It That Way) 

Due to COVID-19 pandemic, National Association of Social Workers will hold its June 14-17 “virtual” instead of meeting in Washington, DC.  American Sociological Association (Aug. 8-11 in SF) cancelled, and Hawaii Pacific Gerontological Society (Sep. 9-10 in Honolulu) postponed. #share aloha