November 26, 2018

Robots to the Rescue?

Earlier this week, the New York Times featured an article entitled Meet Zora the Robot Caregiver. Zora, like her Japanese predecessors, the canine Aibo, the seal-like Paro, and the more recent humanoid Pepper, is being touted as a solution to manpower problems in geriatric caregiving. Can it work? And is it a good idea?

A friend who works in the robotics field reminded me of the potential of robotics when I wrote about the shortage of human caregivers to meet the needs of the coming wave of baby boomers entering old age. She acknowledged that today’s robots are limited in their abilities but is optimistic that when she and I may need their help—in 20 or 25 years—they may be ready. 

What exactly are robots being used for in the caregiving arena? Robots are being used for nursing home patients with dementia: they are used to calm people who are “antisocial, agitated, or sad” and asan antidote to loneliness. They provide reminders to forgetful elders to take their medications or go to the dining room for a meal. They show older people how to perform various exercises—repeatedly and with no sign of impatience. 

I have no doubt that robots are coming—this week also saw the publication of an essay in the New Yorker called Roomba Nation, which emphasizes the wide range of functions that robots can serve. Pepper, the previously alluded to  service worker in nursing homes, is also an employee of the hospitality industry. Paro (the robot seal robot) and Aibo (the robot dog) are purchased not only by nursing homes but also by facilities catering to disabled or depressed individuals. Robots clean floors in private homes and provide room service in hotels. And I have no doubt that robots can perform invaluable activities—minesweeping and disarming IEDs come to mind. 

But let’s be careful about just what tasks they replace and which functions they perform. Not that long ago, we began overhauling nursing homes so they would not serve merely as warehouses for older people, many of whom have cognitive impairment as well as physical disabilities. The practice of placing nursing home residents in wheelchairs, belting them in with restraints, and lining the chairs up in the hallway where nurses could “keep an eye on them” fell out of favor. It was replaced by an attempt (perhaps realized more often on paper than in reality, but an attempt nonetheless) to create a home-like environment where older people would feel valued and respected, and where they could find meaningful ways to spend their days. Critical to a sense of value, respect, and meaning are relationships. And relationships are between people. 

David Oliver, a geriatrician and general medical consultant in the UK, worries that the robotics industry may be driven in part by “marketing, the financial bottom line, and passive acceptance of workforce gaps.” Taking issue with the claim that robots can “provide rehabilitation…deliver personal care, and reduce social isolation,” he reminds us that “we should never forget that health and social care is a people business (emphasis added) and that those people might prefer more, not less, human contact.”

So—before we endorse the tagline, “robots to the rescue,” let’s think about the domains in which robots truly have something special to offer. In the nursing home setting, they could literally lighten the load for nursing aides, who right now have one of the highest rates of on-the-job injury in any industry, if they could lift patients out of bed and onto a wheelchair. That’s no easy task, both since we have to worry about the robot applying excessive force and crushing the person, and because frail, older people aren’t likely to remain motionless while they are lifted into the air. They could engage in monotonous, repetitive actions such as bringing lunch trays from the kitchen to their designated recipients. In the home setting, they may be able to provide 24/7 safety monitoring for older individuals with frailty or dementia, potentially allowing them to remain in their own homes with a spouse. But let’s make sure that the robots’ roles are to complement those of flesh and blood human beings. Let’s enable nursing aides and other caregivers to establish and maintain relationships with the subjects for whom they provide care. Let’s find ways to promote this newly reimagined career path to more people than are interested in today’s dead-end, low-paying, back-breaking jobs. Robots can help but they are not the solution.

November 19, 2018

Yearning to be Free

For the past couple of weeks, I have not found any burning geriatric issues to report on. So instead, I will discuss a burning moral issue, an issue that emerged 75 years ago--so perhaps in that sense it is a geriatric issue.            

            Nearly 76 years ago, on New Year’s Eve, 1942, three teenaged girls made their way through the snow and under a barbed wire fence from France to Switzerland. Cold, frightened, and desperate, they saw asylum in Switzerland as their only hope. They had been sent by their parents from their homes in Germany to Belgium to avoid persecution in 1939. When the Germans invaded Belgium in 1940, the girls had escaped to southern France where they lived in an abandoned castle with 100 other Jewish refugee children. They had been rounded up by the French police and would have been transported to Auschwitz if their supervisors from the Red Cross had not managed to intervene. They knew there would be another roundup and they would not be so lucky again. They knew that their days in France were numbered.
            The girls also knew that official Swiss policy was to turn away Jewish refugees who crossed the border. Despite the intelligence that had reached the Swiss government about mass murders of eastern Europe Jews, and despite the deportations of western European Jews that had begun earlier that year, the Swiss government sealed its borders in August, 1942.  While narrowly maintaining that it continued to provide asylum to “political refugees,” the government decreed that“refugees who have fled purely on racial grounds, e.g., Jews, cannot be considered political refugees. Such people should be refused entry without exception.” After widespread protests, the Swiss authorities allowed some exemptions, including pregnant women and children traveling alone under the age of 16. The three girls who walked across the border unaccompanied by adults that frigid New Year’s Eve were seventeen. One of them had turned 17 the previous week, on Christmas Day.
            They had no papers, so they lied about their ages—and they survived. If they hadn’t, I wouldn’t be telling this story, as one of those three girls would one day be my mother.  An estimated 24,500 would-be refugees were not so fortunate and were sent back over the Swiss border to face almost certain death.
            In the aftermath of World War II, the United Nations convened a conference on refugees. It was a direct response to the post-war refugee crisis in general and to the mistreatment of refugees by Switzerland in particular. At its heart is the concept of non-refoulement, a principle “so fundamental,” the Convention asserts, “that no reservations…may be made to it. It provides that no one shall expel or return (‘refouler’) a refugee against his or her will, in any manner whatsoever, to a territory wherehe or she fears threats to life or freedom.”
            The Convention was ratified by 145 countries in 1954. Broadened in 1967 to refer to refugees everywhere in the world, not just those seeking asylum during the 1940s, it was ratified by the United States and remains the basis of international law today. The Convention specifically stipulated that refugees should not be penalized for “illegal entry or stay.” 
            The refugees of today, including the group of desperate Central Americans proceeding on foot toward what they believe is their only chance of freedom, look a little different from those of the 1940s. They are women who have been threatened with rape if they fail to do the bidding of drug traffickers; they are adults who are lesbian or gay and are targeted for elimination by extralegal police; they are children whose relatives have been kidnapped for ransom and who fear a similar fate; they are men who have been extorted by organized crime. But, like my mother, her friends, and the other refugees from Nazism who were able to breach the Swiss border in the 1940s, the participants in the “Caravan” fear threats to life or freedom in the countries they come from. 
            We must not make the mistake of confusing “immigrants” with “refugees.” Immigrants are people from other parts of the world who seek a better life in this country. They want to come here to be educated, to work, and to live. The US sets its own policy toward these seekers and there is broad agreement that its current policy should be redesigned to better reflect our national interests. But refugee policy is set by international law. It is based on the enduring principle that anyone whose life or liberty is endangered in his home country and who manages to reach a freer country, however he manages to get there, is entitled to asylum. To violate that precept by failing to allow refugees to make their claims for asylum is to flout the internationally agreed upon principle of “non-refoulement.” It is to return to the barbarism of the past.