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Ageism in the Time of COVID: Podcast with Louise Aronson

In this week's GeriPal podcast we talk with Louise Aronson, author of the Pulitzer prize finalist Elderhood (listen/read our podcast with Louise on her book here).

Louise has been one of the (sadly) few voices beating a loud and urgent drum in the medical and lay press about the insidious ageism taking place in the time of COVID.  In a prior podcast we discussed the ways in which structural racism contributed to vast disparities in COVID, and similarly in this podcast we talk about the ways in which COVID exposes existing ageist assumptions, attitudes, and systematic forms of discrimination.  

To give a sense about how prolific Louise Aronson has been writing about ageism, here are links to just a sampling of her articles in the NEJM, New York Times 1 and 2, VOX, Forbes, and the Atlantic.  She also mentions this terrific piece by Nathan Stall and Samir Sinha during the podcast.

And wow - love the song choice - It's the End of the World As We Know It by REM.  Sure seems like it these days.



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Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, it's been a while since I saw you.

Alex: It's been a while. I got a haircut.

Eric: Oh nice.

Alex: COVID haircut. I couldn't take it anymore, shaved it all off.

Eric: Wait, I see somebody else on our Zoom call.

Alex: Yes, we are fortunate and honored to have a return guest, Louise Aronson who is with us today, who's a Professor of Medicine at UCSF in the division of geriatrics. She's the author of the book, Elderhood, which is a Pulitzer Prize finalist. We did a podcast with her about that book. We'll have a link to that in the show notes. She's been writing furiously in the midst of this COVID epidemic, about ageism. There are articles in the New England Journal, Times, Vox, Atlantic, Forbes, and other outlets soon to come.

Alex: Welcome back to the GeriPal Podcast, Louise.

Louise: I am honored to be on twice. I feel like that's some kind of stature. I have to figure out what to do with that. I was going to say frequent flyer miles, but those are not so useful lately.

Eric: We'll give you a branded GeriPal face mask, how about that?

Louise: Oh, that would be awesome.

Alex: We need those. That's actually not a bad idea.

Louise: You need them. I would wear that, I'm going into all these senior facilities. I would totally wear that. And they would say, "What is on your face?"

Alex: We had GeriPal tee-shirts at one point. This is non sequitur. We'll get to the song, but I would wear the GeriPal tee-shirts. I wore it to my kid's elementary school, and this guy looks at me and says, "GeriPal, is that like PayPal for older adults?" [laughter]

Louise: That's actually really smart.

Eric: How embarrassed were your kids from wearing that tee-shirt, Alex?

Alex: No, they love it, really.

Eric: Great.

Alex: "Dad's famous, he's on YouTube." [laughter]

Louise: How to make it in the eyes of your children.

Alex: That's right.

Eric: Louise, we always start off with a song request. You got a song request for Alex?

Louise: Okay, well I have to admit I've been doing a lot of public health, and the whole ageism thing. So I picked R.E.M. It's the End of the World as We Know It. Just to be clear, it's not the end of the world, full stop.

Alex: Right.

Eric: Is that the song request, or are you just making a statement that it's the end of the world? It's hard to tell.

Louise: Well, that was one of the songs, that's one of the two songs going through my head. I'm hoping I'm not predicting the future.

Alex: I hope not too. But things are bad, COVID, George Floyd, and then we have unmarked officers pulling people off the street in Portland and throwing them in vans.

Eric: Don't forget murder hornets.

Alex: Yeah.

Louise: And poverty, really bad poverty and hunger. Yeah, looking pretty great.

Alex: Yeah. This is the appropriate song for the time. I will try to get through it without stumbling, which is hard with this tongue twister. But, I love this song, so thank you for requesting it.

Louise: Sure.

Alex: (singing).

Louise: Wow, that was awesome! You did it!

Alex: A first time for everything, yep.

Louise: It's really great.

Alex: Well thank you, that's fun.

Eric: I mean Louise, there are so many things that I'm worried about right now. And that we're all worried about so many things going on in 2020, some of these things have been lasting for centuries. Do I have to add ageism as another thing that I need to worry about right now?

Louise: Eric, you're seriously not already worried about ageism, and you call yourself a geriatrician? I think you need to hang your head in shame. [laughter] That is just terrible. Yes, you should worry about ageism, because we live in this crazy world where nobody wants to die. People want to stay alive, and they want to do all these things, but it's not okay to grow old. And because it's not okay to grow older, or even talk about growing old, we create a world that isn't really set up for old people. And then we blame old age for any challenges they have. It's crazy.

Louise: And also, I really feel like if we start killing off one population, it's a pretty dramatic slippery slope downward to killing off other populations or writing off other populations. You breach that ethical line and we're all in trouble.

Eric: Just read your Atlantic article not too long ago again. You start off the conversation on the Atlantic article with a hypothetic of what if this pandemic really just mainly affected the other end of the age spectrum, younger adults, school-aged children? And how would we react as a society differently? Do you think we would have? And do you think ageism is playing a role there?

Louise: Definitely. Would we have the vice president saying "Steer clear of children?" Would we have this incredible person, the commentator, Bethany Mandel who said something like, "You can call me a grandma killer." Like, "I'm not sacrificing my home and food, and all our doctors and every form of pleasure just to make other people comfortable." Which was sort of a broad thing about lockdown versus not. But there was an ageism. Or the Lieutenant Governor of Texas Dan Patrick, who said, "Old people should just sacrifice themselves." Should children sacrifice themselves? Should 40-year-olds sacrifice themselves?

Louise: Is there an argument like, at least these are people who lived full lives? Yes, but again, if you start saying like certain people are of less value, then you end up, well actually you end up with human history, which is depressing. But okay, so let's try and rise above that. You end up with racism. You end up with sexism. You end up with ableism. You end up with this cycle that we have in society of saying, "Well, those people aren't worth as much because of the work they do. And the lives they lead." And you don't add into that equation, what opportunities we have or haven't given them.

Louise: We also look at kids and we'll say, "Well they're the future." Well, can't you look at older adults and say "Well, they're what gave us our present." There's way in which we have this endless double standard about old age. And I just think it's dangerous, and it allows us to take all kinds of shortcuts and get away with things. Like saying the problem is theirs. And it's also really, really strange because it's the only-ism really where you're having a prestigious against your future self. You would think self-interest alone would get rid of this, and yet it's been present throughout human history so there's definitely something to it.

Eric: Why do you think that is? Why do you think we have that, as the only ism that is about our future self? You'd imagine that we would be mindful of that.

Louise: Yeah. I think some people are better at that than others. But it's so common that I think you can't actually necessarily give people too hard a time. I think more we need to encourage them to see it that way. Part of it I suspect has to do that we all start young. And everybody's more comfortable with the group they're in. And so there also is this phenomenon with ageism which isn't so true of otherisms, it's not unseen in otherisms, but of internalized ageism which is profound and ubiquitous. So usually you don't get internalized racism or internalized sexism. You do get some of that, internalized homophobia, et cetera.

Louise: Although often those things are responses to social pressers, the little Black child who picks the White doll with blue eyes, because we're all taught those are the better people. The gay person whose pretending to be straight. There is this, but it's fairly uniform among older people. And I think it's because we imprint on ourselves as young. I also think that was how I could write Elderhood when I was in my fifties, because when I became a geriatrician, and I hear this in our fellows and younger faculty members, they're talking about them. At some point you realize like, "Oh right, this is me too." You get it intellectually, but you don't get it until it starts happening to you.

Louise: I've had so many patients over the years say, "I look in the mirror and I think, who is this guy? Who is this woman?" They feel like their younger self. It's like, I think it's related to that thing they say about music, like I know this is true for me that I know the words to songs I didn't like when I was a teenager, and I still know the words, but I can't remember a really important article from last week in the New England Journal, right? Because certain things imprint on you when you're young, and so there's that.

Louise: And then there's also the fact that life is a bit of an arc. People talk about you go full circle, you get to your second childhood. No, we keep moving forward, but it's shown as an arc because there's this point of increase of high power in middle adulthood where not everybody, and actually we have more and more older people running this country for better and worse, et cetera, and running big corporations. But there is this sense that you had something and now you're losing it. I think the extreme case of this is that people who are trying to make extreme longevity make it so that humans don't have to die. These are almost exclusively powerful males. And so they're at the top of the human hierarchy and they can't bear the thought of falling down at all.

Louise: And that is more of a universal experience that we have as we get older where old age instead of being seen as elder, I mean that was part of why I called the book Elderhood, is seen as an inferior adulthood, instead of as a progression into the third major stage of life. So, it happens commonly and naturally, and that doesn't mean we can't do something about it.

Alex: I'd like to hear more about how you see ageism playing out in your everyday clinical practice. And this is something that you wrote about in New England Journal. I wonder if you could share with us any stories you have from your clinic, experiences as a geriatrician, caring for patients in this era of COVID?

Louise: Well you see it in all sorts of different ways. I mean, I think a way I see it commonly is somebody has gotten sick, whether they're at home or in the hospital. And they've gotten a little deconditioned. And so often will start them on some physical therapy, some rehab. And there are exceptions to this but often what I see is that they're not pushed enough, either not by themselves, not by their families, not by the physical therapist, not by their primary doctor. That everybody assumes you're old and now you were sick, and so now you're going to be worse off. And there's not much you can do about it.

Louise: Whereas we actually know you can build muscle, and you can regain function, and all these things. But it takes a little longer. Things are definitely slower as we get older. So can we do things? Yes we can, but not if you don't try. And I'll write on my prescription, "I want you to do resistance training with this person." And sometimes it still doesn't happen. They won't give them the weights. You have to build the muscle to get the functional capacity. We also see, and we're seeing a lot of this with COVID where early on, the geriatrics community knew absolutely that people were presenting with confusion, that they were presenting with falls, that they were presenting by fainting, the more likely and frailer, and older, older adults.

Louise: There was actually interesting data from Italy so that it was corroborated in at least one other country. There was abundant data that this was happening. But the CDC didn't include confusion until May in their list. We pushed hard at UCSF to get it included at least, but then they would include it on the outpatient's side, not on the inpatient's side. And then I'm part of our San Francisco Department of Public Health response, and we just heard about a facility where a woman in her 90s stopped eating which is another common presentation, and they let her not eat for three days. And then they found her unresponsive and sent her to the hospital.

Louise: So, we keep seeing this. And it remains not on people's list. So it's what we expect of people. We're not acknowledging they present differently, that needs are different. And that progress is possible. If you assume something's impossible, and you don't work for it, it's not going to happen. And then you say, "Oh yeah, old age sucks." But you've created that reality.

Alex: Just as the COVID epidemic has exposed underlying systemic racism, structural racism, we had a podcast about this as well. We can link to on our show notes.

Louise: I like that one actually, it was great.

Alex: Thank you. You've really pointed out that its exposed systemic ageism in our system. And I wonder if you could comment on ways in which you've seen ageism operate on a health system, national policy level, allocation of resources, et cetera, during COVID.

Louise: So many ways. One way is clearly the symptom list because you're not looking for symptoms, you're not going to find them and recognize it is COVID. And actually the New York data suggests that part of the reason older adults didn't do so well was that they went in saying, "I'm sick." They weren't tested for COVID because they didn't have any of the COVID symptoms, they were sent back home. And then they came back in really sick, were admitted and tested positive because those symptoms weren't being recognized.

Louise: But there are all kinds of other things. One of the metrics of whether you're in surge or not has to do with whether health workers have sufficient PPE. So in most of these metrics, it doesn't include people who work in nursing homes or other elder care facilities, even though those have been the places where most people have died.

Alex: Right.

Louise: Disproportional numbers of people. And that's actually kind of a twofer, or maybe a threefer, societally, right? Because you're not protecting the old people, you're not protecting the workers who are the poor people and often the people from the communities of color who are also disproportionately getting sick. Instead, you're giving it to the advantaged physicians at the advantaged hospitals. So then we say, oh, it's this nursing home travesty. And yes, are there things about nursing home policy and the way nursing homes are run that are contributing to this without question. But it is also our national policies and our health system, and public health systems, failure to acknowledge that these people matter and deserve PPE.

Louise: On an even bigger scale, I don't know if you guys saw Sidd Mukherjee had an article early June or early May in the New Yorker, and he talked about how in Japan, they had a crisis and they repurposed factories to make equipment, like it was a car factory, I'm not going to get this right. And they repurposed other factories so that they could avert this national crisis, and meet a need in a key manufacturing sector. So we could as a nation have way more N95s. I spent part of this morning looking up K95 versus N95; are they as good? Do they say, okay, we've got to use it because that's all we have? CDC says we can't follow the manufacturing chain.

Louise: We could as a country be making, I mean five or six months, we could have been making N95s. All these old people who are locked up and depressed, and losing conditioning, losing mental function. If they had a fitted N95, they could go out; they could live. And then they wouldn't be such a burden on the health system. We've created effort.

Eric: Yeah, I'm thinking back, there's so much focus on things like ventilators early on.

Louise: It's classic.

Eric: It really hasn't panned out, but a simple N95 mask, this far into it, why are we still having shortages? Why are we still talking about this? Even in a healthcare institution, let alone giving it to the most vulnerable population so they can actually avert some of the risks. It's shocking.

Louise: No, we literally can't get it. I'm doing a site visit at a facility that's had several cases. How do I find one? And then the K95 maybe it doesn't need to be fit tested? So if it doesn't need to be fit tested, does that mean the air could ... It's just like, are you kidding me? And people say these things and it literally does not occur to them that this is systematic structural ageism.

Alex: Yeah. I wanted to ask you as you were talking about going to a facility, you work for the Department of Public Health in San Francisco. I wanted to ask you more about that by way of signaling to our listeners that there are things they can do about this as well. And our listeners as you know, are primarily clinicians, some researchers, but overwhelmingly clinicians, geriatricians, geriatric nurse practitioners, palliative care docs, palliative care nurses, social workers, chaplains. What are you doing locally? And what can our listeners do locally to combat ageism in the era of COVID?

Louise: Well, if you can be part of any COVID-related effort, you should be. I mean, at the beginning they were calling for people to help in the hospital in ICUs. So, I last worked in that setting in the 1990s in any serious way, so I'm thinking you would be getting not good care if you received it from me. So I was thinking, well what else can I do? Because there're so many ways you can help and use what you know. So obviously I was writing the articles, and I was volunteering at UCSF, but then we didn't surge, we didn't really me. So then I looked at the Department of Public Health and for me it was that people I had trained, one guy who was ahead of me as our health officer and the guy who's in charge of health services for the city was a year behind me. So I just wrote them a note and said, "Look, can I do anything?"

Louise: And then it turned out that the Department of Public Health was really happy to have geriatricians. They hadn't come to us, but they actually were even willing to pay us. So a group of us had been working there. And they need us, right? So they have a lot of people who have a lot of expertise in infectious disease. And they don't know anything about old people or old bodies or what matters in older lives. Or even the facilities we're going into, they'll make these comments and then some of them will go out on these site visits, they'll be like, "Oh my God. I had no idea. How do you do this? And what does this mean?" And they don't know. And these are, I mean, I want to be completely clear, these are incredibly hard-working, dedicated people who kill themselves to help in the pandemic. None of this is intentional.

Louise: If I had to deal with babies now, what would I do? I did PEDs in 1990. So we just have to acknowledge really good people can do harm because they don't know what they don't know. And the more we're in the room, and sometimes also they'll want to put out these policies or guidances, there're so many problems with them. And yes, negotiating that takes weeks and sometimes months, and it's hard work, and it can be frustrating. But none of that would be happening if the group of us from UCSF weren't at the table. So I think anybody can volunteer in ways of large and small. We have some people doing a few hours a week. And other people doing most of their job now.

Eric: We've had past discussions about rationing of resources. Certainly we've touched upon it here with PPE supplies. We've had Doug White talk about rationing of medications to treat COVID. I'm wondering from your perspective, how you're thinking about ageism and our response to limited resources with this pandemic?

Louise: I think this is part of my larger response to this. Well yeah, if you let someone get critically ill, it's super expensive. But guess what, prevention is way cheaper. And also the people are happier because people would actually rather not get sick in the first place, than get really sick and get excellent care. And yet the entire financial structure of the American healthcare system is about cutting-edge science and treatments for this rare disease, and this kind of intensive. If you look at the buildings, and it's not just our institution, I also should be clear about that. I travel all over the country and everybody's got their precision medicine, and their genomics and their heart center, and their cancer center, and their this, and their that.

Louise: Does anybody say, "Oh my gosh, let me show you our primary care center." "Let me show you where we teach people really how to exercise and figure out something that they will do in perpetuity." "Let us show you our test kitchen." "Let us show you how we're really working with the community, not just putting up a poster on the side of a bus." We have plenty of money in our health system. The problem is where we put it.

Eric: Yeah, I guess the other question, the followup question to that too is, I read a couple of your articles, and there's also a focus on advance care planning, focusing on vulnerable populations and having these discussions. I guess the question is, how much focus should we have on that? Is this a perpetuating this ageist issue of, "Oh you're getting it sick, so we better have this discussion because you're a vulnerable population and you're going to die from this."

Louise: Yeah, I totally agree. We just had this whole hullabaloo at SF Department of Public Health about a, What's Your Risk for COVID flyer that was all about old people, be careful going to see old people. Old people are high risk, and all of us the senior [HUD 00:24:06] were like, "Oh no, don't do it." Yes it's true, and everybody needs to wear a mask. And again, that was well meaning, and not untrue. And the problem is, we really have trouble as individuals and as a society with complexity. So it can be true that it probably does make more sense to do advance care planning if you're over 80 in the age of COVID. And, we shouldn't write you off entirely.

Louise: There have been some pretty good studies. There's that European collaborative, the article in the Lancet about frailty. And it was very clear that it had much more to do with frailty than with age. And a lot of older people are pushing back on this. There was an article in the Washington Post recently about somebody who was 62 talking to other people in their early 60s, and they're like, "Hey, we just found out we're old." But is our risk the same as the risk is the person whose bed-bound in a nursing home and 98, and has advanced dementia? They're thinking not, and I'm thinking they're right. So there's a way in which we don't really discuss the gradations. And maybe is it that it should be universal, or that it should be universal for anybody in any of the higher risk groups?

Louise: At the same time, I have a lot of patience and I know of a lot of people who are some of them over 75, certainly anybody over 85, who says, "Look, if I need a ventilator, forget it." Not everybody but really almost everybody I've spoken to, because that's not going to go well for me. Do I want everything up until then? Yes. But if we don't ask those questions, I mean, this is again our crazy health system, right? So you could have a frail 80-something or 90-something year old with multiple other conditions on a ventilator for weeks, costing probably millions of dollars, certainly hundreds of thousands, for care that he or she doesn't want and will never recover from. But we can't get people the PPE they need or do the advance care planning, acknowledging that ...

Louise: I was on a program where somebody was talking about putting books at every pediatrician's office. And handing people books. We do things for different age groups. Maybe this is what we need to do. And we also just have to get people used to death and using the word death. Because, if you're in your 80s or 90s, you know it's going to happen in the relatively near future. It happens to all of us. But I'm constantly also hearing clinicians saying, "Well they passed on." Or, "They passed away." If we can't use the word death, no one is every going to get comfortable with that.

Alex: Back to the hospital for a moment, I'm interested to hear your perspective on visitor policy for older adults. Most hospitals still have restrictions in place around visitors, and this is potentially detrimental when a patient has dementia, or is at risk for delirium. And their loved one and caregiver who they know, their familiar face, is not allowed in. And then you can see the other side of it too, we don't want to put that person at risk. It exposes the other patients in the hospital and healthcare workers to an additional person from outside. Interested in where you come down on this issue.

Louise: Well, I think there're two main issues here. One is the difference between a friendly visitor and an essential caregiver. An essential caregiver is a person whose presence either pragmatically provides care for you, or keeps you from declining in your physical health. So we're also seeing this across nursing homes and residential care facilities, and Nathan Stall and Samir Sinha in Canada have just published something last week that was great on this distinction. And I can send you the link after if you don't have it. But I think that's a really important distinction. We think of caregivers as only being paid but the fact is particularly in elder care, most caregivers are not paid. And if somebody's going downhill, absent their family or friend caregiver, that is an essential worker, and so should be allowed in. So that's one part of the perspective.

Louise: We also have to acknowledge that when a person gets sick, a person who previously was their spouse or their child might become an essential caregiver in the setting of delirium for example. Even if the person didn't require care prior to becoming delirious or hospitalized. The second thing is that most of the places that have not allowed family support for older patients, have allowed family support for children. So either we are allowing in supports to people who need them or we are not. That is overt structural ageism. So you say this is a vulnerable population, it's kind of like, and we do this at all levels of society, but you abandon your kid, you go to prison, you get in trouble. You abandon your elderly parent, nothing. No biggie. We just need to impose these standards consistently.

Eric: Yeah, talking about imposing standards, I was just thinking, we've definitely had, we've done podcasts on the disparities in care with COVID. And certainly reading every major medical journal right now, it is a topic on healthcare providers' minds. And there's rightfully an outroar over this, with that said. We've all played our role in making healthcare look like healthcare does. You don't see that outpouring of emotions around, you mentioned in your article, 80% of all deaths are in older adults. So there is this huge difference in who is getting the disease and who's dying from it. And you're not seeing these publications coming out around ageism and honestly when you see these numbers, I think for most people, like, "Thank God it's not happening to younger adults."

Eric: We've talked about messaging around structural racism, how to actually approach some of these issues when we see them. Is there messaging around this? Are there ways that we can respond as clinicians? We are pretty much shown right upfront that there is ageism going on here.

Louise: Yeah, I think an important thing is it shouldn't be a competition and of course you can be Black and old simultaneously. And that's actually not so good for you. Because often these things are synergistic more than additive. And you could be Black, and female, and old. I mean, it just goes on and on and on. So, I think that one matters doesn't mean another doesn't matter. Are there some differences? Yes. Some of the people who are now being discriminated against had very privileged lives previously whereas if you are Black in the United States, even before you're born, were doing harm to you. As a system, when you look at the birth outcomes and things like that, so that is a little different.

Louise: At the same time again, it doesn't mean that ageism doesn't also exist and matter. And I actually think a system that starts looking at its isms as a whole, I mean, we basically have this health system that was created by privileged men of a certain age and race in their own image. And it has been changing a little bit, but not enough. If you also look at the history of medicine, what you'll see is we started admitting more women to medical school classes in the 80s. And women's health really came to the fore in the 90s. We started adding more people of color to medical school classes in this century. And now we've got white coats for Black lives and people standing up for that.

Louise: And throughout society, there's a point where people get a voice. In medicine, it's hard for older people because you're not, I mean, you'd have to be an absolute lunatic to go into medical school at 80. I can't even imagine doing that. Forget it, right? So they're never going to be part of that decision. But on a societal level, I also think people, we have such a sense of like you've had your time, don't speak up for yourself, that people feel like they can't make noise. And maybe it'll call attention to how old they are and that's like the worse thing about them. So, it's changing a bit.

Louise: I think the silent and great generations really didn't stand up for themselves. I mean, you'd have people in excruciating pain who wouldn't admit it. But we're also doing better, and I do think that's why we're starting to see more of this. And in fairness to Gen Z, maybe in particular, and a variety of others, but there was a lot of comment at least initially on the nursing home crisis and all the deaths in nursing homes. And we've never seen so much press about aging. But has it followed through to its logical conclusion? And has it gone beyond just sympathy to actually looking at the structures that cause these problems? But we also have tons of young people volunteering, and making a difference.

Louise: I do think if the older people who aren't already vulnerable, would stand up for themselves and say they're old. Like RBG does it, but do we hear Nancy Pelosi or Joe Biden or Donald Trump, you know, I mean whichever side you're on, Mitch McConnell. I mean, there're so many of them, right? Those are old people. Those are old people in power. And they don't lobby. You have the Black Caucus. You have the women's groups in Congress. You don't have like the old age group, because nobody wants to be part of it. So, now I can't even remember your question, I really apologize.

Alex: Louise, you've been leading the charge in so many public outlets and medical journals around this issue of ageism. I wonder who else you see as being a leader and thinking ahead and thinking clearly about this issue? And who are you reading, and listening to about this topic?

Louise: There are so many good people. There's Ashton Applewhite, who wrote This Chair Rocks, and has a TED Talk that's been powerful. And some people, in the geriatrics community, fault her for being on the side of the fitter or younger old. And I actually think there was some of that early on, and now she's really looking at the intersection of ageism and ableism, and thinking more broadly. So I think she's someone to look out for. I mentioned Nathan Stall and the group in Canada are doing things. Mike Wasserman has been very vocal about the nursing home crisis. He and I have discussed some of his techniques would not be something I would do, and yet they worked. He was all over the news.

Louise: So, I think there are so many different ways we can speak out for this. And you have to call it, but you can call it in a really polite way. I mean, I seriously believe certainly in our medical circles that people are not, even in the public health effort, there've been all these things where we're just like, those of us in the senior HUD, like, "Oh God, it can't be true." And yet everyone who worked on that, worked hard and meant well. So I think if you start understanding that, that people aren't out to get old, I mean yes, there're some people out to get old people. But most of the people we get to interact with are not in that boat. And so, you need to explain.

Louise: There're a lot of time, I mean, I can't tell you how much time I spent crafting these emails. I mean, it's a stupid email, right? But you have to say it in a way that people can hear it, and I also find comparing it to things that they're used to looking at and showing how it's a perfect analogy is really helpful.

Eric: My last question for you, you have a magic wand, you can make two to three changes right now with that wand. Do you have a couple of things that you'd do? Let's focus on the healthcare system or healthcare providers, things that they should be doing differently.

Louise: I was going to say, I would have to do global poverty if we were going big. But, you have all these people starving to death, that's really not good. So healthcare system.

Eric: Yeah, specifically around ageism.

Louise: Around ageism. I would, this is big, but you did say I had a magic wand. So I would restructure medical education, and clinical services, and research dollars proportional to use of health services. So that there would just be structures and money and time devoted to aging all the time because who uses health services the most? So I'd probably do that. I think overhauling time and buildings and money, money in particular.

Eric: Wonderful. Anything else you'd like to add, Louise, before we get a little bit more of R.E.M.?

Louise: At the End of the World? I guess, maybe I'll reference the song. So It's the End of the World as We Know It, so there are some things we're all missing, like hugs and certain friends, and traveling, et cetera. And so if the world is ending in that regard it's not so good. But I don't think the world is ending completely. And the ending of the world as we know it, might also mean the end to structural racism, the end to old people being cut out of health system, the end to nursing homes that aren't like homes but are more like prisons. So think of this not as, in the song, they talk about all sorts of things that are wrong also. But every time we're seeing things that are wrong it's an opportunity to do it differently.

Louise: And one of the most fascinating things about COVID was how quickly health institutions pivoted and changed all their priorities, services, and funds flow. So we used to say it couldn't be done. We watched them do it in a matter of weeks. So if they don't do it to make for a better healthcare system, so that we actually have a healthy populus, that is a decision they are making largely for their own profits and comfort, rather than for the health of the populus. We know they can do it. They should do it.

Eric: Yeah, I mean, I think there's a lot of things that are making me hopeful right now. I got to say, I don't feel hopeful, especially I feel like things are going in the wrong direction with institutional care, with the pandemic. We are further and further isolating them into institutional care where nobody's visiting, nobody's allowed to visit. I think most hospitals, their visitors are not something that they're concerned about. And I'm usually an optimist, but man, I feel like things are actually potentially getting worse in that regard.

Louise: Well, I keep saying in San Francisco, that so far we have killed more people with our COVID policy than have died from the virus among older adults. And that doesn't even include the harms done, the harms we can't even calculate because we can't get to many of these people. But again, working within, we have a visitor policy, it was already to go. It was actually approved on one day, and then the surge started and it was revoked the next day. We have activities approvals that are about ready to roll out. We can all make a difference on these things. But we also have to explain how important this is. And people who are in charge of this are generally seeing everything just through an infectious disease lens, and an internal medicine lens. And this is where the geriatrics and palliative care lenses that are truly person centered, absolutely need to be invoked and imposed, and tell people, et cetera.

Louise: I think they're thinking we need to make residential care facilities like nursing homes, and we need to make nursing homes even more like isolation units in maximum security prisons. Don't let that happen. We all need to speak up. And the other thing I've started doing is when older people send me notes, I send them a list of all the different people they can contact at the local and state level. And media outlets, they can go to, to make a difference. Everybody should be speaking up.

Alex: That's great. On that note, these lyrics are prophetic in some ways, "A tournament, a tournament, a tournament of lies." What does the sound like? "Offer me solutions, offer me alternatives and I decline." If we only had face masks four or five months ago. And then some are just ridiculous, "Birthday party, cheesecake, jellybean, boom. You symbiotic, patriotic, slam but neck, right, right." I love these lyrics.

Alex: All right, here we go, a little bit more (singing).

Eric: Well Louise, thank you very much for joining us. It's always a pleasure. We're going to have to add you ...

Louise: It was fun.

Eric: Yeah, that GeriPal face mask will be sent your way soon.

Louise: I'm so excited. Swag from the podcast, yeah.

Eric: And to all of our listeners, thank you for joining us, and Archstone Foundation for continued support.

Alex: Thanks everybody. Until next time. Bye.

Eric: Good bye.

Louise: Thanks.