Older Americans Month: Make Your Mark

Older Americans Month is 55 years old, and its celebration has gone virtual due to COVID-19 pandemic.  This year’s theme, Make Your Mark, highlights the contributions that older Americans make to our communities, and the “difference everyone can make in the lives of older adults, in support of caregivers, and to strengthen communities.”  Its website includes activity ideas to share stories to build community using different media, as we continue to stay physically distanced from one another. 

Sharing stories during COVID-19 pandemic

To date, 108-year-old Sylvia Goldscholl made her mark as oldest American survivor of COVID-19, after two weeks in isolation at for-profit Allendale nursing home in New Jersey, where she is known as “inquisitive person who likes smart conversation” and outspoken advocate for other residents.  Never married and without children, she said “I survived everything because I was determined to survive.” 

World’s oldest COVID-19 survivor is 113-year-old Maria Branyas, after several weeks isolated in her room at a care home in Olot, Spain.  She told a reporter, “I have done nothing but live.”  Her daughter runs her Twitter account, established after Branyas was named “oldest woman in Spain,” which included the following tweets translated from Spanish: 

·       “In the solitude of my room, fearless and hopeful, I don’t quite understand what’s going on in the world. But I think nothing will be the same again…you need a new order, a change in the hierarchy of values and priorities.”

·       “It is very sad all that this pandemic has exposed. Older people do not deserve the forgetfulness they have received.  They fought and sacrificed time and dreams for you to have an identity and a quality of life today. They don’t deserve to leave the world that way.”

Mission Hospice Community Education Manager Susan Barber organized Legacy and Meaning Making - Ethical Wills with End of Life Wisdom's Marcy Bernstein from Greater Boston via Zoom! Marcy returned to school at age 60 to earn her MSW, and later met Susan at Metta Institute’s End of Life Practitioners Program. During this two-hour workshop, Marcy guided us through components of writing ethical wills: Opening words (e.g., “Dear Family and Friends, I leave you these things that I have learned throughout my life”); Personal history; Values & beliefs; Religion & spirituality; List lessons & reflections; Favorite things and/or dislikes; Hopes for future (aka controlling from grave); and Concluding thoughts (e.g., “As I close here, I have to laugh because I realize that even at the end of my life, I do not stop giving directions”). 

McSweeney’s published online A Force Outside Myself: Citizens Over 60 Speak, with invitation for submissions (100-500 words).  

Karl Pillemer, who spent 25 years as a gerontologist without ever talking to old people until seeking them out for direction as his “future self,” launched Cornell Crisis Advice Project featuring older people’s wisdom on living through a crisis, with invitation to share advice online. 

Trying to not die prematurely

“Stay safe. Acceptance of death is over-sold. Dylan Thomas had it right. Why not rage against the dying of the light? After all, we’re all going to be dead a long time. An effective strategy for living fully is to not die prematurely. So stay home, wash your hands, wear masks and try not to touch your face.”-- Palliative care Dr. Ira Byock, “A crash course in being mortal,” Medium, Apr. 14, 2020 

Continuing stay home orders since mid-March was not going to be sustainable, without creating additional crises.  It’s not about the economy, but have we reached a tipping point when dangers of social distancing are going to outweigh the benefits of reducing spread of coronavirus transmission? During this pandemic, people can die prematurely from illness unrelated to COVID-19 due to postponing health care, effects of social isolation, domestic violence, etc. No surprise alcohol and gun sales shot up.

Major danger of isolating at home and institutionalization is being cut off from the wider community for protection. Senior centers and adult day centers were forced to suspend in-person operations due to California’s executive order (no gathering in groups of 10+), leaving participants at home alone/cooped up with stressed out caregivers, and harder for center staff to assess elder abuse/neglect because it is unknown whether an older adult is able to speak freely during telephonic check-ins.  The eyes and ears of the community are lost, by continuing to ban family, friends, LTC ombudsman, and volunteers from visiting residents in LTC facilities.

On Memorial Day, Minneapolis community bystanders were present to witness and document evidence of the brutal police actions against 46-year-old George Floyd who repeatedly cried, “I can’t breathe,” while a white male police officer kneeled on his neck in chokehold for nearly nine minutes, supported by his male accomplices, two white officers held down Floyd’s body and one Asian officer blocked bystanders.  Floyd is black, and died in another state-sponsored killing in a country founded on violence from enslavement and genocide.

As America’s death toll from COVID-19 exceeded 100,000, the higher death rates among black and Latinx, low-income, and older people revealed entrenched inequities and arguably state-sponsored killings.  Read Adam Serwer’s “The Coronavirus Was an Emergency Until Trump Found Out Who Was Dying: The pandemic has exposed the bitter terms of our racial contract, which deems certain lives of greater value than others,” The Atlantic, May 8, 2020. 

Bystander intervention = community care

Hollaback and Asian Americans Advancing Justice (AAJC) hosted Bystander Intervention training to stop anti-Asian/American and xenophobic harassment during COVID-19 pandemic.  This free, one-hour training via Zoom covered the spectrum of disrespect (examples of microaggressions to violence; spelled out so one can call out disrespectful behavior), taking steps to be a good bystander (notice scenario and assess own safety, notice your concerns about intervening), and deciding which of 5 Ds to use to support someone who’s being harassed, emphasize harassment is unacceptable, and make our community safer:  

·       Distract: indirect approach to de-escalate situation; e.g., to build safe space, start conversation with person being harassed like ask for directions (“Can you tell me where the closest grocery store is?”), or find another way to draw attention away from them (drop something)

·       Delegate: get help from someone else; e.g., find person of authority…think about calling police?

·       Document: make sure person is being helped first (call 911), covertly film harassment by pretending to check email; offer to give to person who experienced harassment and let them decide what to do with it

·       Delay: after incident is over, check-in with person who experienced disrespectful behavior

·       Direct: speak up about disrespectful behavior when it’s happening; e.g., “Hey, stop. Language like that doesn’t belong here”

Presenters took polls on how we would respond (multiple choice listing 5 Ds) to various scenarios involving in-person and online harassment of Asians (not include police brutality).  As a former investigator, I favored Document, in the tradition of George Holliday, who videotaped Los Angeles police officers beating Rodney King in 1991 and set precedent for citizen journalism.  Brave bystander 17-year-old Darnella Frazier filmed Floyd’s killing by Minneapolis police officers (someone else called ambulance; no one wore face masks), bringing out the truth that woke people to pandemic of systemic racism and demands for justice/peace.  In times of unrest, support investigative journalism for speaking truth to power!

In addition to racism, the 5 Ds apply in confronting ageism, intervening when witnessing elder abuse, and reporting to LTC ombudsman (if incident occurs in LTC facilities) or Adult Protective Services (if incident occurs in home/community).

Last year, photo and video evidence of elder/dependent adult abuse by staff at Laguna Honda Hospital was uncovered during a human resources investigation of sexual harassment involving SF DPH employees, who used their personal cell phones to record their own abuse of residents.  Appalled to learn that mistreated residents were from the unit where I volunteered to take residents outdoors for fresh air and conversation… I considered resigning as volunteer, took time out before deciding that the presence of community volunteers is still needed to keep watch over what goes on in total institutions, which can be dysfunctional workplaces (why I preferred volunteering to take residents outside).  SF DPH Director denounced the “culture of silence” that enabled the abuse to take place over three years harming 130 patients/residents. As part of reforms, Laguna Honda posted reminders to report suspected abuse and no use of cell phones/other media recording devices without prior written consent. Due to COVID-19, Laguna Honda suspended volunteers program since March 3, and then excluded visitors and non-essential staff.  Who’s looking out for residents now?

Women know how to live longer?

According to SF DPH’s COVID-19 data tracker based on 66,988 test results reported: 2,558 positive cases (60% men) and 42 deaths (28 male, 14 female; 25 age 81+, 6 age 71-80, 8 age 61-70; 19 Asian, 10 White, 7 Latinx, 4 Black). Males represented 67% of COVID-19 deaths in SF, and similarly greater proportions of COVID-19 deaths in U.S. 

SF DPH improved reporting to provide breakdown for age 60+ into 3 brackets; however, it continues to report cases among Asian monolith (just like PBS series on Asian Americans), who have highest death proportion, rather than Asian national origin groups.  According to SF DPH, Asian COVID-19 deaths are associated with older age — roughly 90% were age 60+, many were residents in LTC facilities, and some were connected to cruise ships.  The New York Times reported how concerns over coronavirus transmission is upending Chinese tradition of sharing food with chopsticks.

The mostly lethargic COVID-19 response has revealed underfunding of our public health system.  Perhaps one bright spot has shown that women leaders appear more effective than men in their response to COVID-19—acting first in making the “bold and unpopular” call to pause normal life, perhaps because women understand vulnerability, humility (listen to credible infectious disease experts, not Sweden’s Anders Tegnell!) and mutual aid based on their lived experiences?  SF Mayor London Breed empowered SF DPH and supported health equity efforts in response to COVID-19 pandemic, and Santa Clara County Public Health Officer Sara Cody, MD, spearheaded unprecedented SF Bay Area stay-at-home orders.

Outside of SF Bay Area bubble, media has touted female leaders for taking similarly effective COVID-19 responses to save lives: 63-year-old Taiwan President Tsai Ing-wen, PhD (law professor); 65-year-old Germany Chancellor Angela Merkel, PhD (quantum chemistry); Norway PM Erna Solberg; Iceland PM Katrín Jakobsdóttir; Denmark PM Mette Frederiksen; NewZealand PM Jacinda Ardern; and Finland PM Sanna Marin.
 

Not counting Hong Kong, which is “governed” by authoritarian puppet (63-year-old female social worker turned President) of mainland China and her strong-armed police; however, honorable mention to Hong Kong’s people power for effective COVID-19 response including impressive mask distribution to poor and elderly, installing hand sanitizer dispensers in crowded tenement buildings, massive strike of medical workers to demand PPE and closing borders, etc.  Hong Kong’s people power includes prominent infectious disease experts like Dr. Kwok Yung Yuen, who helped discover SARS virus in 2003, and recently published his study suggesting that surgical masks can reduce spread of coronavirus by up to 75%! (Dr. Yuen shared his expertise at this month’s UCSF Asian Health Institute town hall meetings via Zoom.) 

Storytelling via film

Center for Asian American Media (CAAM) “reimagined” its annual film fest to virtual presentation (rather than postpone/cancel event given temporary closure of theaters due to COVID-19), CAAMFest Online: Heritage at Home! AARP hosted the screening of You Are Here documentary featuring life stories of SF Chinatown residents (clip included 1948 Miss Chinatown Penny Wong moving into assisted living), followed by Q&A with Dorothy Quock, 86-year-old lifelong Chinatown community leader, researcher/field producer of Good Medicine Picture Company, Wok Wiz Chinatown Walking Tours leader, and “Chinatown Pretty” style icon.  Since SF’s stay home order, she shared that she had been in her 480 sq. ft apartment for 64 days without leaving her building except once to get seven loads of laundry done!

Harm reduction

SF extended stay home order “indefinitely,” and abruptly added curfew as another emergency measure in response to violence/arson/vandalism/looting that broke out during demonstrations protesting police killing Floyd.

Deferred v. instant gratification? When 103-year-old Jennie Stejna recovered from COVID-19 after two weeks isolated in her Massachusetts nursing home, she asked for beer and got it.  When unhoused people are cooped up in hotel rooms during quarantine, SF DPH supports them by delivering alcohol, tobacco, medical cannabis and other substances—as harm reduction—to prevent them from going outside to get substances themselves. 

In theory, harm reduction saves lives…by mitigating risk of coronavirus transmission as more realistic option than eliminating risk without creating other public health risks such as depression and anxiety associated with prolonged social isolation. Harvard infectious disease epidemiologist Julia Marcus wrote, “Quarantine Fatigue Is Real: Instead of an all-or-nothing approach to risk prevention, Americans need a manual on how to have a life in a pandemic” in The Atlantic (May 11, 2020); some take-aways: 

1.   Policy makers and health experts can help the public differentiate between lower-risk (outdoor settings, increased ventilation with physical distancing) and higher-risk (enclosed, crowded settings; prolonged, close contact) activities for coronavirus transmission, and offer support for the lower-risk ones when sustained abstinence isn’t an option.

2.   Acknowledge that people’s decisions and their risk of coronavirus transmission are based on context.  For example, the decision to join “reopen” or BlackLivesMatter protests on the streets conflicts with SF health order banning large gatherings, but perhaps for some people the relative risks of coronavirus transmission may be outweighed by the health benefits of social justice solidarity, exercise, and being outdoors.

3.   Instead of shaming people who choose to engage in higher-risk activities, empower them with tools to reduce any potential harms while being mindful of need to flatten curve during COVID-19 pandemic.  For example, if a healthy older adult wants to join comrades in protests, offer public heath guidance on how to do this by reducing risks: wear face masks and protective clothing, maintain 6 feet physical distancing (stick to edges?), avoid physical contact with others, keep hands clean, avoid touching face with unwashed hands, no yelling (expel more potentially infected respiratory droplets), don’t share food/drinks/utensils, and don’t get arrested because jails are very high-risk!

In New York City, 2 out of 3 patients hospitalized for coronavirus had been staying home—so obviously there’s more to staying safe and reducing risk of coronavirus transmission.  In “Social Distancing Is Not Enough: We will need a comprehensive strategy to reduce the sort of interactions that can lead to more infections,” The Atlantic (May 22, 2020) writer Derek Thompson offered SAFE guidelines: 

·       Social distancing (6 feet between yourself and others, especially when you are near others for an extended period of time)

·       Airflow awareness (every noncontact activity—talking, eating, working out—becomes significantly safer outside in open-air environment)

·       Face masks (wear them)

·       Expectoration (beware of droplets that spray out of mouths during activities like talking, singing, shouting, or heavy breathing, especially circulating indoors)

Joe Allen, Healthy Building program director at Harvard T.H. Chan School of Public Health, recommended higher ventilation (open window to bring in more outdoor air, use portable air purifier to filter out airborne particles inside buildings) and close toilet lid before you flush.

Obviously, there is need for humility and caution when so much is unknown about novel coronavirus, but how about acting on what we do know? Scottish Intercollegiate Guidelines Network (SIGN) issued Presentations and management of COVID-19 in older people in acute care, noting that older people are less likely to present with cough, fever, or influenza-like illness; what to look for: delirium; anorexia; vomiting, diarrhea, abdominal pain; low-grade fever/absence of fever; fatigue; falls; acute kidney injury.

CMS issued guidance on reopening nursing homes to visitors—no new COVID-19 cases for 28 days, no staff shortages, adequate PPE/disinfection/testing.  Since this is unlikely to happen anytime soon, could we consider a SAFE harm reduction approach like allowing visits in outdoor spaces—along with Atul Gawande’s four pillars for safe reentry into communal spaces (hygiene measures, physical distancing, screening, face masks)?

According to California DPH, 35% of COVID-19 deaths are from residential LTC facilities, which are largely invisible to the community, especially since the lockdown in March.  Senior & Disability Action (SDA) hosted Crisis in Care town hall meeting via Zoom, to respond to the huge proportions of COVID-19 cases and deaths in LTC facilities. Presenters Mike Dark of California Advocates for Nursing Home Reform (CANHR), Charlene Harrington of UCSF, Dave Kingsley of Gray Panthers, and Wendy Duchen of SEIU (union of nursing home workers) repeated shortages of PPE/testing, and longstanding problems with underfunding LTC, understaffing, low pay of staff who work multiple jobs, for-profit nursing homes that exploit unprotected staff and undermine resident safety, poor infection control practices, weak regulatory oversight, etc. 

No one mentioned the fact that LTC facilities are workplaces, defined by hierarchies and politics that can be toxic, and there is only so much Management-By-Wandering-Around to set a different vibe for greater transparency and accountability.  Most people wish to age in their home, not at a workplace!

SDA’s call to action:   

·       Demand nursing homes provide safe staffing, PPE, infection control, case and death transparency 

·       Demand Governor deny legal immunity sought by nursing homes for COVID-19 deaths in their facilities

·       Demand Governor not cut community-based Long-Term Services and Support (LTSS) programs that keep seniors and people with disabilities out of dangerous/potentially deadly LTC facilities

A week after SDA’s Crisis in Care meeting, U.S. Senate Hearing on Caring for Seniors amid COVID-19 focused on LTC facilities. University of Chicago Health Professor R. Tamara Konetzka testified that nursing homes with the lowest % of white residents were more than twice as likely to have COVID-19 cases/deaths as those with highest % white residents; nursing homes serving non-white residents were most vulnerable, located in and staff from predominantly non-white neighborhoods that are most affected by the pandemic.  She also testified no relationship between CMS ratings and profit status on COVID-19 cases/deaths. Her recommendations included: testing/staffing/PPE resources to LTC facilities; resources to enable prospective/current residents funded by Medicaid to receive services at home rather than institutional settings; requirements for data collection and transparency; and consolidating LTC payments into single consistent program. 

Other LTC news:

·       SF DPH made progress towards universal COVID-19 testing (still using nasal swabs instead of saliva test), prioritizing “vulnerable” populations and began testing residents and staff at nursing homes. 

·       Alzheimer’s Association recommend LTC ombudsman and state/federal CMS surveyors designated as “essential” to equip them with PPE and authorize their visits to LTC facilities (48% of nursing home residents and 42% of ALF residents have Alzheimer’s or related dementias) 

·       Profits before people? California Department of Social Services offering $1,000 per day for assisted living facilities (ALF) to house COVID-19 patients discharged from hospitals, heightening risk in ALF which are not health care facilities and not equipped with infection control. Medicare reimbursement to nursing homes taking in COVID-19 patients is 4x more than long-term residents.

·       Media’s continuing failure to distinguish LTC facilities.  Examples: Nils Lofgren, 68-year-old guitarist with Bruce Springsteen’s E Street Band, filed a lawsuit against Brookdale Senior Living—referred in news reports as assisted living or nursing home—after his 83-year-old mother-in-law contracted coronavirus; 44-year-old Janie Kasse found workaround to maintain in-person contact with her 65-year-old mom Carol Chesser at Windsor Ridge Assisted Living, in report by Good Morning America headlined “Woman takes on 3rd job to work at mom's nursing home during coronavirus pandemic” 

·       Kudos to non-profit Jewish Home SF on preventing COVID-19 in NPR and Wired 

·       Hong Kong had zero COVID-19 deaths in its care homes due to strict infection controls; HK University Social Work Professor Terry Lum said, “Protecting the elderly from the virus is protecting the healthcare system, which protects everyone.”  

Need to do better

·       Governor Newsom’s May budget revised to eliminate Community Based Adult Services/Adult Day Health Centers.  What was he thinking? Thousands of older people already at risk for institutionalization could end up in nursing homes, which is costlier and deadlier during COVID-19 pandemic.

·       U.S. not sign United Nations Secretary-General Policy Brief on COVID-19 and Older Persons  

Age-friendly developments

·       Expansion of slow streets

·       Toward digital equality: SF Tech Council/Community Tech Network’s Home Connect delivers device (10” Android tablet), internet and virtual training to seniors who live alone with no internet access yet motivated to be tech savvy 

·       Great Plates Delivered SF provides 3 restaurant meals daily (through June 10) for seniors at risk due to COVID-19, live alone, unable to obtain/prepare own meals and other criteria 

·       SF High Risk Community Housing (HRCH) Program provides complimentary hotel accommodations and meals (through June 30) to SF residents living with others in neighborhoods with high COVID-19 rates 

·       California Master Plan on Aging meetings resumed after 2.5 month pause and released LTSS Subcommittee Report 

·       Think about improving Medicare