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There are reasons why so many younger — and older — adults ignore public health warnings about Covid-19, says geriatrician Louise Aronson.

In the early days of the U.S.’s coronavirus response, the Centers for Disease Control and Prevention advised everyone to steer clear of crowds and wash their hands more, urging “older adults” especially to stock up on food and medicine in case things got worse. The news from China was that Covid-19 had been more fatal among people who had underlying health conditions, and who were over 65 years old. The first wave of public health admonitions emphasized that strict social distancing measures were necessary to protect the vulnerable elderly.

But younger people, as is now well known, are hardly immune: Not only can heathy young adults be asymptomatic carriers that become vectors of the virus to parents and grandparents, they can also be victims of it; about a quarter of Covid-19 patients hospitalized in Italy are under 50.

Still, the lingering presumption that coronavirus is merely a disease of “old” people is having damaging consequences — witness, for example, the extremely poor social distancing adherence among Spring Breakers on the beaches of Florida this week. The calculus of pandemic suppression — and arguably, being a person in the world — means that everyone needs to be looking out for everyone, whether they’re old, young, sick or healthy. So far, the U.S. is failing this test.

CityLab spoke with Louise Aronson, the author of Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, to learn more about how the American relationship to age and aging is affecting the way we’ve understood the Covid-19 crisis, and how to recalibrate. Aronson is also a geriatrician and professor at the University of California, San Francisco. Our conversation has been edited and condensed for clarity.

First, how are you? How is this crisis affecting you and your family?

So far so good. It’s just weird, it’s so weird — there’s both no time and more time and then you’re worried, but some things are totally normal. I guess that’s what they mean by unprecedented.

Are you going into work at UCSF anymore?

Basically they’ve said that everybody that doesn’t need to be in there doing stuff should go home. I am principally an out-patient clinician and I’m also an academic, so I work on a variety of projects. For clinic visits, the good news that came out today was that previously you couldn’t bill for telehealth visits for most patients because Medicare couldn’t cover it, but today they announced they’d cover it. Do you need a physical exam for some things? You do, even in this modern age, so some people may need to be seen, but a decent number of things hopefully we can manage well enough. What you lose sometimes in physical exam you might gain by not having more people not getting sick right now. It’s keeping the most vulnerable patients at home.

Public health agencies have recommended extra Covid-19 precautions for “older adults” and people with underlying conditions, who are more susceptible to a serious or fatal case of the virus. But we seem to be seeing a lot of confusion about what that means. Can you help define what people mean when they say “old”? Both now, in the context of dealing with coronavirus, and generally?

As I’m sure most people know, this is a hotly debated issue. Among the youngest people, old is anybody over 30, of course, and among the oldest people, old is anyone over 85 or 90. There’s an old joke: “Old age is always 10 years older than I am.” I think a lot of people feel that way throughout the many decades of what I like to call “elderhood.” The way I’ve been thinking about it draws on human biology and changes in our physiology, in our risk factors, in our ability to handle drugs, in our immune systems, as well as by the way societies have legally and socially defined old age.

If you go back thousands of years and look at Iran or Egypt or Greece or Rome or China or Japan, “old” always comes in somewhere between the ages of 60 and 70. But if you tell most Americans in their 60s that they’re old, they’re going to say something along the lines of: “I’m still fully functional, etcetera, etcetera.”

Being old doesn’t mean you’re not fully functional. It doesn’t say anything about your function! All it speaks to is the number of years you have been alive and your biology. When people who are older — and they are the most likely group to do this, although some younger people do it too — and still functional say, “I’m still functional,” they are inadvertently contributing to the very ageism that leads them to make that denial.

What they’re saying is that when they — when we all — become less functional — which happens to anyone who lives into advanced old age, and most of us will — we no longer have value as human beings. We no longer deserve compassion and attention. And I strongly dispute that.

I don’t want to make this out like it’s a personal failing of anybody but it’s so universal. It is as universal as ageism itself, which we see in ebbs and flows throughout history and culture. I’m not blaming people, but I do believe we have a moment here. As our population shifts from one with lots of kids, fewer adults and almost no old people to one — barring disaster with this pandemic — that’s fairly equal people in all age groups, we have an opportunity to see old age more realistically.

Has that psychological aversion to seeming “old” affected the ways people over 60 have responded to this health crisis? We’re seeing reports of Boomer parents and grandparents refusing to take the social distancing precautions as seriously as some of their kids, for example.

People seem to be doing this for a couple different reasons. Some of them just don’t buy that this is a pandemic. There are certain news outlets and individuals who are perpetuating that myth, or have been. Based on where they get their info, they truly believe this is part of a plot by one party to oust the leader of another. They’re just misinformed — perhaps lethally misinformed, which is tragic.

And then there’s the other group, where if you don’t think of yourself as old and the restrictions are for old people, then going out almost proves your point.

Although the media is saying it’s “old” people, I know at my medical center it says “anybody age 60 or older.” That’s really based on the data from Wuhan, where we saw as late as January that the rates of death were very, very low in the young but that as your age goes up, so does your chance of dying — dramatically. With case fatalities of .2 to .4% in the young and nearly 15% in over 80-year-olds, the chance of death is around 50 times higher. So the risks are real, and yes if you’re more frail you’re more likely to die.

This actually is a teaching moment for geriatrics: In geriatrics we don’t deny that chronological age matters, but we also know that in terms of health risks and health outcomes, that age is one part of a complex formula that also must include your functional abilities, like can you walk a mile, can you go up and down steps, how strong is your grip. We know that these are tremendously strong predictions of health in old people, unlike in adults and kids.

A lot of people who think of themselves as healthy have high blood pressure, or have a little bit of heart disease but it doesn’t really influence their everyday life; they’re thinking, well, I’m not like a sick person with heart disease. But if you get the virus, you still have a 68-year-old heart.

I think our ageism is such that it’s putting people in a position of feeling the need to prove themselves. It’s almost as if, if they’re not out there doing things, then they’re one of those old people that doesn’t count. We have created that cultural reality, so shame on all of us.

On the other side of the spectrum, many younger Americans — at least at the beginning of the crisis — were less cautious. One theory is that they figured they were safe because they had a lower fatality rate. Was our response to this modulated by our perceptions of elderly people?

Maybe in some ways. Today I was just tweeting about this headline that said “Not just older people: Younger adults are also getting the coronavirus.” When you say “just” older people, it sounds like, well, it’s just killing old people, they’re all dying anyway. Which isn’t true. These are people working and living lives!

We say that the average life expectancy of an American is 79 years — there are huge differences by race and sex, but that’s the average. And if you look at the medians, half of Americans currently live past age 80. Which is a lot. If you’re a pretty healthy 85-year-old woman, chances are you’re going to live another decade. Most people would see an 85-year-old and say, well she’s on her way out anyway. But she had another decade of life.

I firmly believe that if we do more planning population-wide — but also are smarter about older people and target them in ways that aren’t just diminishing but are empowering, as we all want to be targeted — maybe we can prevent some of the illness and not get to the point where we have to take these draconian measures.

Some of the most shocking reports out of Italy came from hospitals where there weren’t enough ventilators for everyone, so doctors had to start triaging patients — making hard choices about who should get further care and who wouldn’t, based on their condition and often, their age. How do you think U.S. hospitals will approach a situation like this?

We’ve rarely done it, except for in war, and some people would consider it quintessentially un-American.

At the same time, we’ve been pretty slow to respond. There were clear messages from the people who can do modeling of epidemics and who understand viruses; the sorts of scientists and experts who have been routinely devalued in recent years. Had we listened to them — and had we still had an office in the federal government that dealt with this, instead of having certain leaders lying about the threat — that action would have made the sort of rationing we consider un-American not necessary.

Are there still steps we can take? Yes, and I think a lot of brave leaders are taking steps. We’re all sheltering in place [in San Francisco], and not everybody’s listening to that, but we should all as citizens be doing everything possible. In every family we can probably find people — not just older people — who are at risk. Because once you start devaluing people based on one characteristic, then you have precedent with which to devalue other people.

How should we be looking out for our communities right now, regardless of age?

In San Francisco, homelessness is in every single neighborhood now. The income inequality is blatant — and that’s before this. I think there are lots of groups we’re looking at here.

There are levels of things you can do: There’s showing support and care, which frankly has been proven to make everybody healthier, strangely. There’s actual practical support, like people in apartment buildings can knock on the door of the older neighbor and say, “Hey can I do anything for you?” I’m seeing interesting things online about being at stores and finding either poor families or older people who can’t afford their groceries and paying for them — if you can afford to do that, it’s a lovely thing to do. We can keep the social distance and still be helping out.

There are coronavirus-care love languages, kind of?

Totally. Think of creative ways to be supportive. There’s pretty good data that people that behave that way are happier than people who are mean. It’s kind of a win-win.

Also: If you’re out and about, because you feel that you’re safe to do so, you should be cleaning. Clean door handles! Wash your hands those 20 seconds with hot water and soap! Most of us have someone in our families who is old, and most of us will become old. We are right now creating our futures by our behavior.

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