Envision, for a moment, a world in which the rapidly spreading coronavirus is mostly infecting people under the age of 50. Imagine that the death toll is highest among children and that, as of today, the United States had reported more than 104,000 confirmed cases and at least 1,700 deaths, mostly among middle schoolers. Imagine that scientists suspect elders are at lower risk based on past exposure to similar viruses. How would you react to a disease that was mostly killing young people planetwide?
If your imagined reaction differs from your current one, then we must ask some hard questions. Most crucial: Is the reality that elders are most likely to get ill and die from COVID-19 affecting the way countries—particularly the U.S.—are responding to the pandemic? There are many logistical and political reasons why America’s response has been weaker compared with other countries’. But as a doctor, I’ve encountered evidence that suggests ageism is playing a role too, in part because ageism has always shaped the kind of medical care that older Americans receive.
I’m a geriatrician at UC San Francisco, whose medical center consistently ranks in the top 10 nationally and as the best on the West Coast. Our response to COVID-19 has been remarkable in its intensity and scope. During my nearly 30-year medical career here, I’ve never witnessed anything like the system-wide mobilization I’ve seen in recent weeks. And yet some of what I’m seeing is also disturbing, especially because my geriatrics colleagues around the country say that elder-specific needs and medical science aren’t being adequately addressed at their centers either.
For example, earlier this month, the medical-center leadership announced that they had developed special clinical protocols for children and adults with COVID-19. To my knowledge, protocols for elders, the most vulnerable group, still don’t exist. This isn’t a UCSF-specific practice; it’s standard throughout the country. American medicine lumps elders in with adults, despite abundant evidence that drugs and diseases behave differently in older bodies. Additionally, health-screening procedures for visitors were put into place at our children’s hospital at the start of March, while similar procedures weren’t implemented for our adult hospital until two weeks later. You could argue that the children’s hospital is smaller and thus easier to manage; you could also surmise that protecting adults and elders was less of a priority, despite the greater risk of hospitalization and death those groups face.
Transgressions like these are minor in the face of global calamity, but we’re seeing similar decisions being made nationally. With each one, this country loses precious time to take the actions that will limit contagion and save the most lives, old and young: screening those at highest risk to limit spread; documenting the predictably different early symptoms in older people; and creating care pathways that offer options to patients for whom aggressive medical treatment would only prolong suffering and not prevent death.
Let me be perfectly clear: I’m not witnessing the actions of malicious, underperforming people. On the contrary, UCSF leadership has been heroic and selfless, working around the clock to provide the best care possible to those with COVID-19 while protecting other patients and staff. Ironically—no, tragically—that noble intent reveals just how entrenched and pervasive ageism is in American health care. It’s baked into how the field approaches education, research, and the most fundamental procedures, structures, and policies.
Medical schools devote months to teaching students about child physiology and disease, and years to adults, but just weeks to elders; geriatrics doesn’t even appear on the menu of required training. The National Institutes of Health mandated the inclusion of women and people of color in medical research in 1986, but it didn’t issue a similar mandate for elders until 33 years later, in 2019. “The bias is so implicit, it goes unnoticed,” one of my colleagues said of ageism in the American COVID-19 response and in medicine generally. But when you start to pay attention, you see it everywhere.
Take for example, the way my state tracks deaths from the flu, one of the most common and deadly infections. Even though older people are far more likely to die from it, until 2018, the California Department of Public Health counted flu deaths only for children and adults under 65. The main explanation given to the San Francisco Chronicle was that recording the far higher number of elder deaths would be too expensive and time-consuming. The problem is that when the impact of disease in a population is unknown, there’s little incentive to develop treatments tailored to that group’s needs. When the affected population is elders, the problem is especially bad: As we’ve already seen with the current crisis, many people say that elders are dying anyway and tend to blame old age itself for their deaths—not a flawed system.
Public responses to the coronavirus pandemic on social media have laid bare the not-so-subtle interplay between medical culture and American culture at large. Reactions to the virus’s spread in the U.S. range from blatantly ageist (the nicknaming of COVID-19 as “the Boomer remover” among some young people) to genuinely helpful and empathetic (some grocery stores reserving certain hours for elderly customers). Between these two poles lie stereotyping and reductionism: Recently, a Washington Post article about a large Florida retirement community highlighted different responses among older people to the outbreak. Some residents refused to practice social distancing, echoing misinformation they’d absorbed from certain media outlets, while others expressed fear about falling ill. A majority of the comments responding to the article, however, focused on the former reaction, castigating “old people” as a whole for being irresponsible.
As a geriatrician, I’m keenly aware of the immense health-care barriers that older people face, with or without a global pandemic. In the second week of March, my clinic was converted to telehealth to protect patients. On Monday, one patient visit went well, another had to be stopped because of multiple technical challenges, and all the others were canceled by patients who told our office staff that they couldn’t manage a video visit. My patients didn’t grow up with any of this technology, and the less fortunate among them live across the digital divide. (This crisis threatens to worsen well-documented inequities in our health-care system, not just for old people but also for people of color and poor people.)
As a child, I learned about the “population pyramid,” or the triangle that illustrates the world’s demographic composition: lots of children, fewer adults, and very few elders. Today, we instead have a column, representing the much more equal numbers of children, adults, and elders in society. Long, full lives are our new normal—thanks in no small part to modern medicine. If the coronavirus pandemic has upsides, I hope one is that it challenges doctors, politicians, and everyone else to more thoughtfully adapt to this new reality for the human species.
Everyone can help create a less ageist culture and improve individual institutions. Aging experts like myself are (for now, digitally) collaborating to devise elder-specific protocols for managing COVID-19. These protocols include essential information, such as the fact that body temperature runs lower in many elders, so a thermometer reading of just 99 degrees Fahrenheit in an 80- or 90-year-old might signal fever. In hospitals, these guidelines would include other, less obvious recommendations, such as also allowing patients with dementia or delirium—whether or not they have COVID-19—to have a loved one by their side to limit terror, agitation, and the need for drugs proven to increase the time they will take up a much-needed bed. Such steps can boost early COVID-19 diagnosis and decrease suffering and complications in elders, thus benefiting all Americans by reducing the strain on our health-care system.
I can offer some good news. Both at UCSF and nationally, geriatricians and other aging specialists are starting to be included in teams to revise COVID-19 diagnosis, triage, and care protocols; increase access to telehealth; and evaluate options and ethics as resources become more scarce. This is significant progress. But it’s hard not to wonder where we might be—where older people might be—if their needs and the knowledge of the specialists devoted to them had been considered from the start.
Fortunately, we can still make a difference. Healthy people who are sheltering in place or social distancing can call, videochat, write cards to, and connect safely with isolated elders in their own families and communities. Keeping older people uninfected and alive shouldn’t be the country’s only goal for this vulnerable group, nor should it be once the pandemic passes. After all, living in a society that values your well-being and basic humanity matters, too.