A Day to Shout

        This past week was Rosh Hashanah, the Jewish New Year. I discussed the origins and evolution of the holiday at my synagogue, observing that the original name of the holiday, as indicated in the Torah, the Jewish bible, is “The Day of Shouting.” And what was it that people were supposed to shout about? Originally, they were supposed to shout out their praise of God. Some of the admirable qualities that have been attributed to God are “caring for widows and orphans,” which is biblical shorthand for “caring for the vulnerable,” and “welcoming the stranger, for you were strangers in the land of Egypt,” which is synonymous with accepting outsiders, newcomers into the community. But already early on in Jewish history, and particularly over the last several hundred years, the tradition is that these “attributes of God” are seen as aspirational—as qualities that people should strive to emulate in their own lives. So, translating into contemporary language, on Rosh Hashanah, we are supposed to strive to care for the poor and the sick and to open our doors to refugees.

         But there’s more. Over the centuries, not only have these qualities attributed to God become qualities that people should strive to adopt themselves, but it has also become our responsibility to act. The shouting that we are supposed to do on Rosh Hashanah is not so much singing God’s praises as it is calling out to our fellow man to act. And the actions in question, not surprisingly, include caring for the poor and the sick and embracing refugees.

         The health care bill that is expected to come to the Senate floor this week is the very epitome of how to avoid caring for the poor and the sick. If you cannot afford medications, hospital care, or insurance premiums—that’s your fault. Next time, work harder, go to better schools or, better yet, choose parents who are themselves smart, educated, and affluent so they can assure that you, too, will be smart, educated, affluent—and able to afford to pay whatever it costs to get good care. In fact, if you have cancer or diabetes or some other chronic, serious condition, that’s your fault, too, so why should someone else have to subsidize your treatment? This bill, which pretends to include benefits comparable to those currently available under the Affordable Care Act, is not a means of providing health insurance to all those left out by the three other programs for obtaining coverage: Medicaid, Medicare, and employer-supported insurance. Rather, it is a strategy to gut Medicaid, one of the three pillars of the current system. The ACA was designed to take a three-legged stool and enhance its stability by adding a fourth leg; the latest travesty proposed by Senate Republicans would instead amputate one of the three legs. So, here’s my shout out to my fellow Americans: say “no” to the Senate proposal. Shout out to your senators—especially if you’re from one of those states such as Maine and Alaska whose senators have previously expressed concern about the poor and the sick in their states, or if you’re from one of the states that stands to lose the most from the new bill, such as Florida and Nevada. Shout to those people you know who live in those states that they should shout out to their senators. Make this Rosh Hashanah truly the “Day of Shouting.”

Taking the Heat

When a record heat wave swept across Europe in the summer of 2003, elderly Parisians were particularly hard hit. “French heat toll almost 15,000,” screamed one BBC headline in September. The cause of death: dehydration and hyperthermia. The diagnosis of the problem: not enough air conditioning, made worse by too many physicians on vacation in August. Across Europe, over 70,000 people died of heat-related causes. We thought we were immune: our nursing homes are air conditioned and we have plenty of nurses, doctors, and regulations. But now we have the disturbing reports of 8 deaths among nursing home residents of a facility in Florida in the aftermath of Hurricane Irma. The nursing home lost power and its back-up generator was useless when a critical component, the transformer, failed. Despite access to an acute care hospital across the street, no one thought to transfer the frail, elderly long term care residents until they were already suffering from severe dehydration and/or hyperthermia. What can we learn from this very sad story?

First, we should drill down and look at the specific facility where the problem occurred. All of the west coast of Florida was affected by the hurricane, after all, but only one nursing home lost patients. The Rehabilitation Center of Hollywood Hills is a Medicare and Medicaid licensed 152 bed facility. It is a for-profit nursing home. And if we consult Nursing Home Compare, the site operated by the Centers for Medicare and Medicaid Services to allow consumers to compare the quality of different nursing homes, we find that the home currently has an overall rating of two stars, or below average. Even more revealing is the further breakdown: in the area of health inspections, it received only one star, or much below average, though in quality it got three stars (average) and in terms of the staff: patient ratio it actually got four stars (above average). So what exactly does this mean?

The problem at Hollywood Hills was not a failure to follow the rules—the facility had a back up generator and supplies for seven days (though their ice collection was presumably not terribly useful if they had no refrigeration). The problem was judgment. Nobody in charge determined that conditions were too dangerous and residents needed to be evacuated. They only figured that out after people began dying, although it takes a couple of days for a lethal degree of dehydration to set in. What our current evaluation system for nursing home lacks is the capacity to measure the ability to respond to novel challenges, to be creative. Perhaps we need to set objective standards, not merely relative standards. If we set the bar high enough, then the lowest performing facilities would still be adequate. That said, it’s striking that the overall rating of the facility was poor. Nursing Home Compare is on to something—we need to have a better way of insuring that the poorer facilities improve. 

The other take home lesson from the tragedy is that Hollywood Hills was the canary in the coal mine. Yes, only one nursing home in Florida seems to have behaved with such monumental lack of understanding of what happens to frail old people in sustained 100 degree heat. But the truth is that we will see more hundred degree weather—and more Hollywood Hills behavior—in the future. A recent government report—issued before President Trump and EPA Director Pruitt banned references to “climate change” from official documents, “The Impact of Climate Change on Human Health in the United States: a Scientific Assessment,” makes clear that there will be profound, widespread consequences of rising temperatures. The vulnerable elderly will be among the hardest hit, but they are merely harbingers of what is to come unless we take major steps now.

Make Our Lives a Blessing

Kaiser Health News ran an article this week about “the secret happiness as you age.” It features the story of a 76 year old man who, despite severe heart disease, diabetes, glaucoma, and osteoarthritis, describes himself as a “happy guy.” He can’t see well, he can’t drive, and he has to rest after walking short distances—really short, like 10 yards. So how does he manage to be happy?

His secret is that he focuses on those things in life that do bring him joy—listening to music and audiobooks, and writing. He also derives pleasure from helping others in small ways. The article concludes with a quote from a geriatrician who says that “the real key to happiness at every age and stage—particularly old age—is not material things, but gratitude for life’s simple blessings, like laughter among friends or watching a sunset with a loved one.”

The message that frailty doesn’t have to spell misery is a refreshing one. Readers of this blog know that I spend a great deal of time discussing frailty: defining it, advocating screening for it, and promoting an “intermediate” approach to care for people who have it. I lament the disproportionate time and energy spent on addressing robust old age and dying, two important states but not where most older people spend most of their time. The Kaiser Health article is an important reminder that we don’t need to hide frail people from view as though they carry an unbearable, unmentionable stigma. But what is missing from the piece is the recognition that while individuals who are frail can take steps to make their lives rewarding, the larger society has an important supportive role to play. 

Creating and disseminating the technological aids that can make life enjoyable are crucial: without his audiobooks and his virtual assistant (in the example given, Amazon’s Alexa), achieving satisfaction might have been impossible. We need to make age-friendly environments, like those promoted by the World Health Organization’s “Age-Friendly Cities and Communities Program.” This means building walkable communities, providing appropriate transportation, and linking service providers to individuals. It means developing accessible housing and means for civic participation, along with access to medical care. It means joining the AARP Network of Age-Friendly Communities or local organizations, such as the Massachusetts Healthy Aging Collaborative. Only then will happiness among frail elders be the norm rather than the exception.

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