Some time ago, the well-known science fiction writer Han Song revealed on social media that he had "cognitive abnormalities", but he was not diagnosed with Alzheimer's disease. Recently, he continued to share in Weibo . Although he put a prompt note at home and office, he still forgot to change his glasses, wear a hat, and bring his mobile phone. After get off work, he went to the wrong unit building. In order to resist the disappearance of memory, he began to record his daily life regularly, "giving memorandums to himself and for interested people to study."
science fiction writer Han Song on Weibo.
In the initial post, Han Song once popularized the meaning of "dementia" to the public, and those symptoms that were considered "old and confused" actually caused him great trouble. For a long time, people seem to have assumed that "being old" is a normal phenomenon of aging. As long as they live long enough, people's memories will always decline. Even Louise Aronson, a well-known geriatric expert in the United States, thought so before becoming a doctor. She later realized how deep the prejudice existed. "Old and confused" is the common name for dementia. There are more than 70 causes of Alzheimer's disease alone, but as long as the elderly do not suffer from any of these diseases, they will not get dementia even if they live to the age of 100. In other words, "confused" is because of illness, not because of old age.
However, it is precisely because of the bias that when elderly patients initially show related symptoms, they are often attributed to "ageing older" and delaying the best time for treatment. Since the 1980s, regular research reports have also found that doctors often miss the diagnosis of dementia. Compared with the actual proportion of disease, the number of patients recorded is much smaller. Why did such a result?
In the past 30 years of medical career, Aronson has come into contact with all kinds of elderly patients and recorded the true stories of clinical occurrence into books. Recently, the Chinese version of the book "Silver Generation" has been introduced to China. Regarding the missed diagnosis of dementia, she pointed out in the book that some clinicians do not have the corresponding professional knowledge and skills; some doctors suspect that the patients have relevant symptoms, but often think that there is no need to make a relevant diagnosis because they cannot give a treatment plan; and some doctors directly admit that they lack time and means to diagnose this elusive disease.
In many aspects, dementia is actually a mapping of the current society's response to aging. Aronson pointed out that overall, today's medical systems in various countries actually "do not welcome the elderly." When the elderly suffer from common diseases, they usually show a series of "atypical" symptoms, showing unique symptoms in the life stage. However, children and adults have special doctors, departments and clinics, while the elderly only have "sanatoriums", and there are only a handful of large hospitals that specialize in geriatric departments.
The resident who once worked with Aronson privately lamented that the goal of medicine is to save lives and treat diseases, and it is "not wise" to use medical resources on many elderly patients. It is true that the limitations of medical resources are well known, but the ethical questions that arise from this have to be thoughtful - is the potential future value of a person higher than the value of the social services already provided? Do we believe in the inherent value of people and that everyone deserves good medical care?
"The Generation of Silver Hair: Redefining the Elderly, Reflecting on the Medical System, Reconstructing Elderly Life", written by Louis Allenson [US], translated by Jiang Yiqi, Zhang Guanglei, Zhou Zhe, CITIC Publishing Group August 2022.
What’s more regrettable is that age discrimination in the medical field is just a microcosm of a bigger problem. According to Aronson, there is an unwritten "rule" in the American elderly medical circle. If the word "elderly" is used in the name of a center or project, it will be difficult for the institution to obtain financial support or recommendations from peers, unless these words are replaced with euphemisms such as "health" or "longevity", even "elderly doctors" are often implicitly called "referral medical doctors". Behind the avoidance of talking is the "fear of old age" sentiment secretly flowing in social consciousness. Coincidentally, when "70 years old is another 50 years old" is popular in American society, the Chinese Internet is also filled with declarations that "youth is a teenager until death.""We created such a society, while living as much as we can, while being afraid of getting old."
and other metaphors abound. Let’s think back to what are the most common words when we talk about old age in recent years? That's right, "Silver Tsunami" has almost become synonymous with aging. Aronson mentioned in the book that the deep emotions expressed have long been conveyed inadvertently - the "tsunami" means disaster, and the number of elderly people in our society will destroy the familiar lives. When society always looks at the elderly group from the perspective of "other", aging can only be a "problem" that needs to be dealt with.
As the time when the new book was published, we interviewed Aronson via email and talked with her about the misunderstandings in the treatment of geriatric diseases. The current medical system’s discrimination against elderly patients also extends to the social "phobia" emotions and age bias, and these ultimately point to the choice of elderly care. During the interview, Aronson repeatedly mentioned that our society is constantly "pathologizing" the elderly stage. The most urgent task is to change ideas. Society needs to create an atmosphere where everyone can accept aging calmly. At the same time, the medical system urgently needs to place more resources on the elderly department.
The following is an exclusive interview with Louis Allenson by a reporter from the Beijing News .
Louise Aronson, geriatric expert, educator, and professor of medicine at the University of California, San Francisco, USA, guided the construction of health humanities at the University of California, San Francisco. She graduated from Harvard Medical School , and also graduated from the Warren Wilson College Writer MFA program. She has won the Humanism Gold Award, the California Home Nursing Physician of the Year Award, and the American Geriatric Association Outstanding Intermediate Clinical Teacher of the Year Award.
Aging is not a problem of "they", but a problem of "us"
Beijing News: Compared with many books talking about elderly care, this book does not only start from the perspective of medical treatment, but also involves the analysis of concepts related to the elderly, and why the elderly are ignored or alienated in the medical system. It is said that during your college years, you studied history and anthropology and , so why did you choose to turn to medicine?
Louis Aronson: In fact, whether it is history, anthropology, or my later medical turn, the reasons behind these choices are the same, that is, I am very interested in people themselves, whether in the past or the present. I once considered becoming a professor in one of these disciplines, and after repeated weighing, I chose medicine because it not only gives me knowledge and skills, but also provides opportunities to deal with people directly and ultimately benefit others. Of course, as you can see, I still have an interest in social sciences and believe from the heart that if the field of medicine and health can absorb more of it and incorporate it into practice and policy making, it will play a bigger role.
Beijing News: I noticed that before this non-fiction work, your first work was actually a novel "A History of the Present Illness" (temporary translation, A History of the Present Illness), both of which were exploring the relationship between medicine and humans. So what are the differences in the focus of these two works?
Louis Aronson: The main focus of "History of Modern Diseases" is not the elderly. Instead, the book is composed of a series of loosely connected stories, involving doctors and patients from different communities in San Francisco and have different ethnic and ethnic backgrounds. I try to use this to outline a picture of society and medical health, so that doctors and patients can return to "humans", because they may only provide life experience from their respective perspectives and present the correlation between medicine and society. Moreover, since the genre of that book is a novel, my most important goal is to create compelling characters and plots, and to play what literature is best at - using individual story mapping as a whole human race.
"History of Modern Diseases" in English.
"Silver-haired Generation" is consciously dealing with a core topic: what is the elderly.It not only covers the historical review of the concept of elderlyness, but also horizontally involves how different countries and cross-cultural regions view elderly. Additionally, the focus of this book is on medical care. The focus is not only because this is my professional field, but also because the problems encountered by the elderly in this field are actually plaguing the elderly in other regions, whether literally or metaphorically. The book tells a lot of stories about myself, my family, and the patients I took over, and I hope these stories are both sharp and comprehensive enough, and attractive to readers. I do want to write a book that is both novel and useful.
Beijing News: This work is not so much a research discussion, but rather a memoir of you as a participant, which contains your experiences and insights in treating elderly patients in the past 30 years, and there are many details. I am very curious, in the past 30 years of experience, have you changed a lot about your understanding of elderly patients?
Louis Aronson: That's true! When I was a young doctor, I looked at the elderly patients, a bit like I looked at people from other countries, (although) I was very interested in them and I cared about them, but to be honest, I always felt that the problems they encountered were far away from me, and those were not related to my physical feelings or my actual life. However, as I grow older and my parents and in-laws have also entered old age, I feel more and more: we are all getting older, and aging is not a problem of "theirs", but a problem of "our", which is closely related to everyone.
In this book, I try to make the arc of the story string all the different opinions people have about old age. This sounds like a bit "porn", but to be honest, I have actually encountered most of the views, except for the coldest and cruelest ones. I hope readers can find resonance in it and slowly realize that the change in personal perception is beneficial to themselves, their families and society.
I do believe that (at present) the biggest limiting factor facing people in dealing with the aging problem is not the decline of physiological ability—of course, it is undeniable that this is very important—but more important is actually our contempt for the elderly. We have devoted a lot of effort to the young and middle-aged people and are constantly trying various innovations, but we have not given equal investment when facing the aging problem.
"Is it a teenager until death"? Where does the "fear of old age" come from
Beijing News: Not only is it the lack of tangible investment, but in fact, in the face of this necessary stage in life, what flows secretly in our social concepts is a "fear" emotion. Even the 80-year-old man with a cane firmly declares that he is not old yet. The saying "70 years old is another 50 years old" is popular in American society, and there are also many statements such as "youth until death is a teenager". Why are people so afraid of "getting old"?
Louis Aronson: This is a very important question. I think there may be at least two key facts behind this. First, it is difficult for people to accept losing what they once had. Although it seems that the elderly are happier than the young, the former has poor physical functions and is more susceptible to pain. Second, the next stop after old age is death, and humans have always been afraid of death. This shows that there are indeed biological reasons behind this "fear".
But don’t forget that in many fields, people have broken through the biological limitations. Why can’t the elderly field be like this? After all, for a long time in history, once an infection is almost equivalent to being sentenced to death penalty, women cannot decide when they will get pregnant and how often they will get pregnant, and men are powerless to face a decline in sexual ability after middle age, but now it is different. Here are just three simple examples, and I mean, it is entirely possible that we can do better with geriatric diseases.
" The Father Trapped in Time " Stills.
In addition, I also suspect that this "fear" is also related to people's general attitudes and the allocation of opportunities at the social level.People confirm their age and (self) value through subtle feelings and real behaviors. As they age, people of different ages should be allowed to do different jobs, and society needs to build a consensus that what they do is still valuable for individuals and groups, and these should be implemented in the workplace, in the home field, in the parks, in restaurants and anywhere else.
Similarly, we should also note changes in health and medicine. Simply put, if we all pay more attention to disease prevention and improve our lifestyle, start with quitting smoking and eating a healthy diet, and do enough exercise since childhood, which will definitely improve our health. What's more, geoscience may also offer options to delay, or even fight aging.
Beijing News: In addition to reluctance to admit to getting older, there are adjectives related to ageing, such as "weakness", "decline", "disease", etc. You once classified these as "ageism" in an interview and pointed out that this "discrimination" is ultimately "a prejudice against our future self". Can you talk about this observation in detail?
Louis Aronson: Old age is a complete and may last for decades, and it is also a normal, natural and predictable stage in our lives. However, when we pathologize such a stage, we actually create another "world" - people seem to suffer unnecessary pain once they reach this stage. If you think about it carefully, we will not call babies disabled just because they cannot run, nor will we call children mentally retarded just because they are at a low level in intellectual development and emotional cognition, but we do turn old age into an unhealthy state. We have created a society where everyone lives as much as they can, while on the other hand, they are afraid of getting old.
Will diseases become more common as they age? Of course there is no doubt about this, but this is still a bit different from old age itself. If a person lives long enough, he or she will become weak, which is a stage of development that can be seen with the naked eye, just as children will always become teenagers and young people will always enter middle age.
However, for those age groups, the "terms" we use are more of a factual narrative, which points to the age group of people. But for the elderly, the language used to describe them has more or less carried negative meanings, and when these words were first created, they did not have such meanings (in the current context). This is discrimination.
Beijing News: Since the outbreak of the new crown epidemic, you have publicly stated that "age discrimination" may make the epidemic worse. Why do you say so? Now that the epidemic has entered its third year, do you still stick to this judgment?
Louis Aronson: At least in the United States, the reality is indeed the case. When you see people dealing with the pandemic, although the elderly have significantly higher risk of infection than most young people, people have never considered giving them nine key responses, including personal protective equipment and testing reagents. The only exception is vaccination. You will find that when the elderly population is preferred, hospitalizations and deaths have dropped sharply.
In addition, the Centers for Disease Control and Prevention (CDC) even has special prescription recommendations and care algorithms for children and adults, but there is no measure aimed at high-risk elderly groups. Such discrimination exists blatantly and undoubtedly causes loss of life. However, as in most cases, these deaths are blamed on “oldness”, while policies that put high-risk elderly people at risk are rarely criticized.
Is "old and confused" really because of "old"?
Beijing News: When it comes to the elderly, a word that is often linked to is "old and confused". The frequency of this word is used almost as if "confused" is a common phenomenon in the elderly, not a disease. Recently, Chinese science fiction writer Han Song said on social media that his "cognitive ability declines", but the hospital has not confirmed Alzheimer's disease.This incident once again brought the health of the elderly into the public eye. According to your research, what difficulties do the medical field currently have in the diagnosis and treatment of diseases such as Alzheimer's?
Louis Aronson: Before answering this question, we need to clarify whether Chinese also confuses the concepts of "old" and "old and confused" (at least there is this problem in English, sorry, I don't understand Chinese at all). This situation was quite common in the United States in the last century, and even earlier, but it rarely happened in the 21st century.
Many elderly people do not have cognitive impairment when they are very old, and dementia is an age-related disease. Does the brain change with age? I think anyone over 40 will definitely have an answer in their hearts. In fact, some aspects will be improved, such as the increase in reasoning and judgment, and it is easier to draw correct conclusions; but other aspects, such as the speed of problem-solving, memory, etc., will indeed decline. But this is not the same as dementia.
science fiction writer Han Song on Weibo.
Dementia refers to an acquired injury that is sufficient to affect the patient's social or professional ability. There are currently more than 70 causes of dementia, but the most common ones so far are Alzheimer's disease and vascular diseases. However, there are many common risk factors, which also allow us to prepare for dementia prevention.
In fact, some key risk factors are the same as heart disease, stroke and cancer: smoking, unhealthy diet, insufficient exercise, obesity, alcoholism, and hypertension . Although disease history, physical examinations, imaging and some new laboratory tests are effective, the difficulty lies in how to give a clear diagnosis before the autopsy. The bigger problem is that few clinicians have received specialized training in diagnosing and treating dementia, and too many doctors tend to think that if a certain disease cannot be cured (whether it is medication or surgery), it means "powerlessness", but it is not.
Beijing News: So in terms of care, what can the family and friends of the elderly do to provide support?
Louis Aronson: There are many things you can do, such as ensuring that the elderly do enough exercise and often give them some social and intellectual stimulation; prepare hearing aids for people with hearing loss and prepare a pair of glasses for people with poor vision, because the acquisition of correct information will be helpful to the brain. Once the elderly are found to have hypertension or diabetes , they will be sent to the hospital as soon as possible, and at the same time supervise the elderly to quit smoking and drink less.
special attention is to try not to take care of all the affairs of the elderly, so that they can remain independent as much as possible and retain some dignity for them. Many families often "do bad things with good intentions", and they will put the safety of the elderly above their independence. At least in the United States, most elderly people choose to live “independently” rather than “safely”.
Stills of "The Father Trapped in Time".
Invisible Geriatric Department and unnecessary medical violence
Beijing News: As for the medical treatment of the elderly, a systematic "turning a blind eye" seems to exist for a long time. For example, in terms of the division of hospital departments, there are special "pediatrics" responsible for various diseases that children are prone to. However, for the elderly group, this disease is high in the elderly group, most hospitals do not open corresponding "gender departments". Why is there such an "imbalance"? What impact does this have on the treatment of the elderly?
Louis Aronson: This comes down to history, capital and age discrimination. Before , investment in pediatrics in most parts of North America and Europe rose sharply. The state knew that a large number of soldiers would be needed, and the soldiers were young, so they increased their investments in an attempt to reduce the rate of child mortality that was once high at the time. It also has obvious benefits for society itself to save children from death, but (they believe) these are not applicable to the elderly population.An ethical question that arises from this is: Is the potential future value of a person higher than the value of the social services already provided? Do we believe in the inherent value of people and that everyone deserves good medical care?
Economically, in the United States, children's health expenditure is usually borne by parents' insurance, and parents' (private) insurance expenditure is much higher than the universal insurance used by the elderly, that is, the cost of "medical insurance". Finally, as we just discussed, age discrimination is everywhere in society and in medical care.
Considering the aging population and the fact that most deaths occur in the elderly population today, coupled with our actual knowledge of how to postpone or prevent a large number of age-related diseases, we need to set up a geriatric department. Having said that, we do not have a special geriatric department yet, and this is not because there is no relevant data to support the benefits of this move, but even if we put this data before people, people do not believe in what can we do on the (unstoppable) old age. This is the tragedy.
Beijing News: In fact, when it comes to the disadvantages of the medical system in the treatment of the elderly, you mentioned an observation that is somewhat different from the public's understanding in the book. Compared to medical malpractices we know, you are concerned about the violence exerted by "people who do not have problems" - that is, doctors may be doing their best and doing their jobs with all their might, but the effect is violence. Can you talk about what "medical violence" is?
Louis Aronson: The original meaning of violence is any act of force that may or intentionally harm, or even destroy something or destroy someone. The purpose of medical services is not to hurt people, but (doctors) may often do the harm in the name of help. For example, all surgeries are inherently violent - so I also used the expression "necessary Violence".
But I think these "necessary violence" are putting medical staff on a landslide together with the emotional resources required to exert violence, making it easier for them to exert (other) "unnecessary violence" on patients, such as limiting their actions when they are emotionally agitated, rather than considering why they are excited; for example, if they are not waiting for the painkiller to work, they are in a hurry to start the surgery; for example, using the "power" of experts on patients and the patient's dependence on experts' treatment, threatening the patients. Such examples are endless in the real medical environment.
" Dallas Buyers Club " stills.
Beijing News: In 2010, "Obamacare" was officially passed, and a series of policies were introduced in order to detect lesions as soon as possible through enhanced daily examinations and thus reduce medical costs. But since its effectiveness, this change has caused controversy several times in American society. Why is this medical reform plan aimed at benefiting more people difficult to advance in actual progress? What do Americans think about "medical insurance"?
Louis Aronson: This situation is really heartbreaking... In fact, the United States does not have universal health insurance, it just has a paid service system. We have millions of people who don’t have insurance. Facts have repeatedly proved that providing people with health insurance will lead to more timely medical care, fewer diseases, reduce loss of working hours, and reduce mortality. States that adopt Obamacare have seen improvements in their health, and states that prevent their implementation have also seen worsening in their related conditions.
However, the issue of medical insurance has been politicized in the United States, so that Republican is all against medical insurance. To some extent, this seems to have become part of the racism and class problem, and there is a hypothesis that (they believe) people’s poverty is due to individual failure rather than well-documented structural oppression or lack of opportunity.
However, even if we put these arguments aside, we will clearly see from the perspective of "Obamacare" and " federal health insurance " (Medicare, mainly covering the elderly population), and our country's third "universal" insurance "The Veterans Health System", we will clearly see that providing medical services does help improve health, improve children's academic performance, and reduce the number of days of unemployment, so that individuals, families and communities can benefit. But ironically, the public appears to have shown strong support for Medicare (which mainly covers the elderly) but refuses to provide similar health insurance to more young people.
Ideal place for retirement: the premise is to provide more options
Beijing News: Today, when the proportion of the elderly population continues to rise, retirement has become a major problem facing many countries. The first thing that needs to be solved may be the problem of where to spend your elderly care. Compared with elderly care institutions, many elderly people actually prefer home-based elderly care. What do you think about this?
Louis Aronson: If people want to send other people to hospitals or related institutions, people better ask themselves first if this is what you want now or in the future. If the answer is no - in my experience, this is the most common answer - then we need better systems that allow people to retire at home, not to mention that this is their preference.
I also want to add that when we are talking about where older people should live, we are talking about older people, not older people in the general sense. Most elderly people in all countries are independent, and more and more "elderly people" still have jobs, whether they are in full or "working" for their families or communities.
"Say goodbye to the world in a familiar home", Ueno Chizuko , Yilin Publishing House May 2022. Science fiction writer Han Song mentioned this book when discussing the issue of aging on social platforms.
Beijing News: One of the problems of home-based elderly care is that families need to bear the heavy burden of nursing. What can our society do to share such nursing responsibilities? And in your opinion, what should an ideal place for retirement care?
Louis Aronson: Like all other stages in life, for the elderly, there is no place for everyone. We need some options, like we have different types of schools and workplaces, just like when we are 5, 15, 25, or 55, we do different things in school and workplaces.
In the United States, most elderly people still want to stay at home for their elderly care. Why can young people make choices but not in old age? There is no moral excuse for this, especially when restrictions are linked to social projects that should be in place but are not in place, these are not problems for the elderly themselves.
In other cases, for social reasons, people may prefer collective life, and as people age, their spouses, siblings, parents, and friends may all have passed away. If you live with your family, these elderly people may often be at home alone because young people go to work or to school. Then, a group may be able to provide opportunities for meals, activities and exercise together. However, these can be achieved through some day projects. The elderly can stay at home at night and also have the opportunity to help others during the day or arrange their own lives. Everyone has different physical and cognitive situations in their later years, and their corresponding life will be different. The community can also set up some volunteer posts for door-to-door services, just like some countries will set up special child care or disease care posts, and time can be set aside for caring for the elderly.
There are countless measures similar to the above mentioned above. It is not that we have no choice, but that we have not been able to implement these measures. This will endanger everyone. If you are old now, or are taking care of the elderly around you, you will feel more the same, not to mention that we will all age.However, the most exciting thing in this moment in human history is that our generations can solve the problem of aging through large-scale changes and innovations, an area that provides many opportunities for people to make a living if they wish, while promoting overall change in society.
editing/Shenlu
editing/Li Yongbo
proofreading/Wang Xin
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