Article by Justin Davidson

June 25, 2020

This article was featured in One Great Story, New York’s reading recommendation newsletter.

With luck, either you will grow old or you already have. That is my ambition and probably yours, and yet with each year we succeed in surviving, we all face a crescendo of mockery, disdain, and neglect. Ageism is the most paradoxical form of bigotry. Rather than expressing contempt for others, it lashes out at our own futures. It expresses itself in innumerable ways — in the eagerness to sacrifice the elderly on the altar of the economy, in the willingness to keep them confined while everyone else emerges from their shells, and, in a popular culture that sees old age (when it sees it at all) as a purgatory of bingo nights. Stephen Colbert turned the notion of a 75-year-old antifa into a comic riff on geriatric terrorists, replete with images of octogenarians innocently locomoting with walkers, stair lifts, and golf carts.

In Sweden, elderly COVID patients were denied hospitalization, and in some cases palliative care edged over into “active euthanasia,” which seems barely distinguishable from execution. The Wall Street Journal quotes a nurse, Latifa Löfvenberg: “People suffocated, it was horrible to watch. One patient asked me what I was giving him when I gave him the morphine injection, and I lied to him. Many died before their time. It was very, very difficult.”

In this country, we have erected a vast apparatus of last-stop living arrangements that, during the pandemic, have proven remarkably successful at killing the very people they were supposed to care for. The disease that has roared through nursing homes is forcing us to look hard at a system we use to store large populations and recognize that, like prisons and segregated schools, it brings us shame.

The job of housing the old sits at the juncture of social services, the medical establishment, the welfare system, and the real-estate business. Those industries have come together to spawn another, geared mostly to affluent planners-ahead. With enough money and foresight, you can outfit your homes for your changing needs, hire staff, or perhaps sell some property to pay for a move into a deluxe assisted-living facility, a cross between a condo and a hotel with room-service doctors. “I don’t think the industry has pushed itself to advocate for the highly frail or the people needing higher levels of care and support,” USC architecture professor Victor Regnier told an interviewer in 2018. “Many providers are happy to settle for mildly impaired individuals that can afford their services.” In other words, if you’re a sick, old person who’s not too old, not too sick, and not too poor, you’re golden. For everyone else, there are nursing homes.

The nursing-home system is an obsolete mess that emerged out of a bureaucratic misconception. In 1946, Congress passed the Hill-Burton Act, which paid to modernize hospitals that agreed to provide free or low-cost care. In 1954, the law was expanded to cover nursing homes, which consolidated the medicalization of senior care. Federal money summoned a wave of new nursing homes, which were built like hospitals, regulated by public-health authorities, and designed to deliver medical care with maximal efficiency and minimal cost. They reflect, reinforce, and perhaps resulted in, a society that pathologizes old age.

The government sees its mission as preventing the worst outcomes: controlling waste, preventing elder abuse, and minimizing unnecessary death. Traditional nursing homes, with their medical stations and long corridors, are designed for a constantly changing staff to circulate among residents who, ideally, remain inert, confined to beds that take up most of their assigned square footage. As in hospitals, two people share a room and a mini-bathroom with a toilet and a sink. Social life, dining, activities, and exercise are mostly regimented and take place in common areas, where dozens, even hundreds, of residents can get together and swap deadly germs. The whole apparatus is ideally suited to propagating infectious disease. David Grabowski, a professor of health-care policy at Harvard Medical School, and a team of researchers analyzed the spread of COVID-19 in nursing homes, and concluded that it didn’t matter whether they were well or shoddily managed, or if the population was rich or poor; if the virus was circulating outside the doors, staff almost invariably brought it inside. This wasn’t a bad-apples problem; it was systemic dysfunction.

Even when there is no pandemic to worry about, most of these places have pared existence for the long-lived back to its grim essentials. These are places nobody would choose to die. More important, they are places nobody would choose to live. “People ask me, ‘After COVID, is anyone going to want to go into a nursing home ever again?’ The answer is: Nobody ever wanted to go to one,” Grabowski says. And yet 1.5 million people do, mostly because they have no other choice. “If we’d seen a different way, maybe we’d have a different attitude about them,” Grabowski adds.

The fact that we haven’t represents a colossal failure of imagination — worse, it’s the triumph of indifference. “We baby boomers thought we would die without ever getting old,” says Dan Reingold, the CEO of RiverSpring Health, which runs the Hebrew Home in Riverdale. “We upended every other system — suburbia, education, child-rearing, college campuses — but not long-term care. Now the pandemic is forcing us to take care of the design and delivery of long-term care just as the baby boomers are about to overwhelm the system.”

Most of us fantasize about aging in place: dying in the homes we have lived in for decades, with the occasional assist from friends, family, and good-hearted neighbors. The problem is not just that home care can be viciously expensive, or that stairs, bathtubs, and stoves pose new dangers as their owners age. It’s also that, in most places, living alone is deadly. When a longtime suburbanite loses the ability to drive, a car-dependent neighborhood can turn into a verdant prison, stranding the elderly indoors without access to public transit, shops, or even sidewalks. “Social isolation kills people,” Reingold says. “It’s the equivalent of smoking two packs a day. A colleague said something profound: ‘A lot of people are going to die of COVID who never got the coronavirus.’ ”

It’s not as if the only alternative to staying at home is a soul-sapping institution. Back when people traveled for pleasure, tourists regularly visited the Royal Hospital Chelsea in London, where, since the end of the 17th century, veterans have been able to trade in a military pension for a lifelong berth in a soldiers’ collective on an architecturally exquisite campus, located amid some of the city’s most expensive real estate. Those who can work tending the grounds, staffing the small museum, and leading tours. When health crises hit, they can move into the care home, which is on the grounds, overlooking immaculate gardens.

The example of an institution so humane that it seems almost wastefully archaic suggests that we don’t need to reinvent the nursing home, only build on humane principles that already succeed.

Get small.

Grabowski’s analysis revealed one variable in operation and design that afforded some protection from coronavirus: Intimate facilities fared far better than large ones. Fortunately, the country has a growing network of miniature nursing homes, certified by the Maryland organization the Green House Project. Typically, this is a cross between a graduate student house-share and a suburban development. Ten or 12 residents, each with a private room, share a sprawling ranch house. They take their meals together, at a long communal table, sharing their lives with a handful of staffers. “The kitchen is open, so you can see the food being prepared and smell it as it’s cooking,” says Green House’s senior director Susan Ryan. Daylight flows into the common areas and a few steps lead outdoors to a garden or patio.

Ryan says that the Green House network has fared relatively well during the pandemic. Its 229 nursing homes nationwide have experienced a total of 32 coronavirus infections. Only one resident has died of COVID-19. But resistance to a specific disease isn’t the only way to judge an approach. Several years ago, Grabowski co-authored two papers evaluating the Green House protocol, and came away with the sense that a gut reaction might be more reliable than sober analysis. “I’m all about data, but it’s hard not to walk in, take a look, and say, ‘Yes, this is where I’d want to put my family member,’ ” he says.

The goal is to make people feel like they are able to continue the life they have lived for decades, rather than be suddenly transformed into superannuated livestock. “You want a place to feel normal, which is the opposite of institutional,” says Martin Siefering, an architect at the firm Perkins Eastman. “Shiny vinyl floors are not normal. Loud mechanical systems, having meals served to you on a tray — these things aren’t normal.”

The suburban-style protocol is an awkward fit for dense urban settings like New York, where the high cost of real estate conflicts with low Medicaid reimbursements, and airiness is luxury. The New Jewish Home, an Upper West Side fixture, hired Perkins Eastman to adapt the Green House model for a new 20-story building on West 97th Street, with separate 13-person pods stacked by floor instead of spread out on an estate. The project ran into a NIMBY firestorm. Backed by city, but opposed by Assemblyman Daniel O’Donnell, Borough President Gale Brewer, and City Councilmember Mark Levine, as well as an association of neighbors, the project was ultimately defeated in court on a zoning question that had little to do with how best to provide long-term care to seniors. The result is that, in New York, the state of the art is grim.

Focus on how people live, rather than on how long.

The guru of the old-age good life is Hans Becker, an elfin 78-year-old Dutchman who spent two decades as CEO of the social-services agency Humanitas and now runs a nursing home of his own, Residence Roosenburch, outside Rotterdam. The design matters less than the philosophy. “The first value is that people are the bosses of their own lives. We have a ‘yes’ culture — we are not allowed to say no,” he says. Becker involves residents in the life of the place, encouraging them to cook, party, and gather for a drink at the in-house bar. “A barkeeper with velvet eyes and white teeth is just as important as a doctor,” he says.

Becker can sound glib about his charges’ physical ailments, but he is emphatic in his opinion that the old see too many doctors. “You should make an organization where people don’t complain too quick. In nursing homes, the residents are right away complaining, ‘Doctor, my knee’s hurting.’ So the doctor comes, and the nurse, and the physical therapist. But that knee is going and it’s not coming back. It’s better to focus on other things. Happiness lowers cost.”

In effect, Becker believes that the struggle against infirmity and pain is a losing battle and waging it too vigorously carries with it a heavy psychological toll. The pandemic has been ruinous for his ethic of maximizing joy.

“Now the government says you cannot have visitors, you cannot peel potatoes, you have to stay in your room, you can’t be busy,” he grumbles. “To be active is very important for your happiness and self-esteem. Use it or lose it: If you don’t walk, you lose the capacity to walk. Now you can’t go out, everything is done for you. So the home just becomes a waiting room for death. But it’s better to die happy and a little earlier than to die in loneliness and misery.”

De-isolate the old.

Long-term-care facilities, almost by definition, are old-age ghettos, where the frail know only each other, and they get accustomed to losing friends faster than they can make new ones. Cities can alleviate this problem by integrating senior residences into mixed neighborhoods — which is one reason to regret the failure of the New Jewish Home’s Upper West Side project — but often it’s not enough to trust to chance and demographics.

The Danish architecture firm CF Møller and the landscape firm Tredje Natur (Third Nature) won a 2016 competition to reimagine a complex of nursing homes in the Norrebro neighborhood of Copenhagen. “Norrebro was a hard-core working-class area,” says Mads Mandrup Hansen, a partner at CF Møller. “Today, different ethnicities and generations are intermixed. So if you build this facility, you fight gentrification, build a bridge between generations, and prolong quality of life. We basically open up the doors to the neighborhood.” (The project stalled for a while, but is now beginning construction.)

A series of three linked courtyards is crisscrossed by paths and lined with stores, clinics, and social services. The goal is to fuse the complex with the city, to mix populations, and stimulate casual contact — all wonderful goals in normal times and completely at odds with life in lockdown. Hansen admits that the project was conceived pre-pandemic and doesn’t adapt easily to a potential future in which people gravitate to barriers and separation. “That will have to be down to the conduct of the staff,” he says.

Demand better.

In a segmented industry where the interests of nursing-home and assisted-living operators compete for meager government funds, reforming the system will involve rewriting rules and spending more. “If the government put $300 billion into elder care, they could transform it,” Reingold says. “That’s an investment, not an expense. Spending more on quality long-term care would save a fortune in hospital stays.” A night in a nursing home costs Medicaid $200 to $300, depending on the state, while a night in a hospital can cost ten times that much.

The elderly don’t take to the streets, at least not on their own behalf. Some join the young in protesting outrages they have endured for decades, energized by the hope that their children and grandchildren won’t have to. But when it comes to their own daily needs and indignities, they prefer to lobby, vote, and, where necessary, pay. The rest of us are mostly content to hope that the problem will solve itself — or we were, until the pandemic made the system’s failures unavoidably stark.

“There’s a lot of interest in this topic right now,” says Siefering, the architect. “It’s too bad that interest came as a result of a lot of people dying, but it would be a shame to waste that kind of death.”