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Graham Abra wrote this summary.
Chapter 3: Dependence
The chapter begins with the stories of Bella Silversone and Alice Hobson who struggle and are unhappy with their experiences in assisted living and skilled nursing facilities.
Gawande uses these narratives to set the stage for how society has handled the care of people as they age. In the United States, in the early 1900s, if individuals did not have family or financial independence the only option once they were unable to care for themselves was a poorhouse or almshouse. These institutions housed not just the elderly but also the mentally ill, young drunks, and out-of-luck immigrants. Housing was provided in exchange for labor and conditions were generally poor.
Although poorhouses have now disappeared as places of care for the elderly in the United States they have been replaced by institutions that often require us to give up most of the control of our lives. How this happened is the story of the medicalization of natural aging.
In 1946, the Hill-Burton Act provided large amounts of federal funding for communities to build hospitals. Medicine was becoming more powerful and for the first time was actually curing previously fatal diseases. Social security might have provided financial support but it didn’t “cure” infirmity and so the hospital became an attractive option for the elderly infirm.
Unfortunately medicine had no answer for the ravages of time and chronic illness so the hospitals began to fill with the elderly who were unable to care for themselves as the poorhouses emptied and closed through the 1950s. As their beds overflowed hospitals lobbied for help and in 1954 funds were made available for custodial units that provided a place for patients in need of extended “recovery.” Thus was born the “nursing” home.
In 1965 the Medicare bill passed and payment for medical services for elderly Americans in facilities that met basic health and safety standards was available. Unfortunately many parts of the country lacked access to such places and so, fearing a political backlash, the concept of “substantial compliance” was created – allowing facilities that were “close” to the standards and trying to improve to qualify for payment. This opened the door to profit through underfunded service. With a belief in the power of medicine to cure and payment on hand, 13,000 nursing homes were built by 1970, many with substantial quality problems.
The quality problems have improved over time and have been replaced by a focus on control and safety in order to meet payment requirements. The institutions where 50% of us will spend a year a more of lives were not designed to make life worth living at the end – they were designed to meet other goals.
After losing her love for life and signing a DNR, the chapter ends with Alice’s death.