Hit old people

Is it allowed to hit frail old people? Most people will agree with me that the answer is no and that you abase yourself if you abuse others. But is it allowed to push them a bit when they are demented and try to run away? And is it allowed to sell frail old people a vacuum cleaner when they can not remember anymore that they already have one? Or is the family member that cares for the older person and deals with all financial matters allowed to use some of the savings to have a well deserved holiday, “because mother really wants me to do that”?

As you understand the possible number of border line cases is substantial and will only grow with the increasing number of older people in the world. It is rather easy to abuse older people, even with good intentions. Sometimes informal carers are so overburdened combining care and work, that they become stressed and do things that they later regret. Not everything can be avoided and arranged but raising awareness is the least we can do. The Dutch government now has a television campaign showing an example of an old man whose model boat was broken by some carer losing patience. The old man is comforted by one of the neighbours trying to find out what happened after hearing the noise.

It is good that the topic is also on the international agenda. Last week I attended a symposium on abuse and neglect of older persons in Europe. It was organized by the European Commission together with the United Nations Human Rights Office. I represented the World Health Organisation, as there are obvious links with ageing, health, care workers, mental health and long term care. But it was also useful for my next job in the ministry, where I will work on long term care and the initiative to come to a new UN convention on older persons’ rights.

Different panels discussed abuse and neglect in care institutions, in informal and community based care and of the ways how to protect the human rights for older persons. In the last panel, we discussed whether or not we need this new UN convention on older persons’ rights. There is no agreement yet in New York and I may go in August to the next session of the Open Ended Working Group (the official name of the committee that deals with this matter).

Another important issue was how to monitor and improve quality in long term care. That will also contribute to avoide abuse, at least in more formal settings. The OECD has recently published a big study on the topic, entitled “a good life in old age: monitoring and improving quality in long-term care”. The report is about how countries are addressing the challenge to protect life in dignity by frail older people by developing measures to ensure a high quality of long term care. Quality measurement in long-term care lags behind quality measurement in health care (leave alone in other industries) and at the moment it is difficult to make national and international comparisons.

Hitting old people is not good. It is a pity that there are some online games where you can practice exactly that. Read this: “Your friend wanted to take his girlfriend on a romantic ride through park, but he can barely go anywhere with all those stupid old people getting in the way. So he asked you to ride ahead of them and make sure none of them ruin their romantic date. Your aim is to ride your saqway and hit the elderly people to keep them in front of you.” Not really the message we want to give to the young generation, isn't it? As you can see on the picture below, there are other and much better online games available, where you can even play together with old people.

 

The ability to think

This week – in my local Eaux Vives cinema in Geneva - I saw the German movie ‘Hannah Arendt`, directed by Margarethe von Trotta. The film is about Arendt's reporting on the Eichmann trial, the Nazi responsible for organising the deportation of millions of Jews. Her book "Eichmann in Jerusalem," stirred up a firestorm by suggesting that Jewish leaders were in part responsible for the extermination of their own people. But the main theme of her work is that she discovered that Eichmann was not an evil man by nature. As she wrote: "The trouble with Eichmann was precisely that so many were like him, and that the many were neither perverted nor sadistic, that they were, and still are, terribly and terrifyingly normal." Eichmann just followed orders, liked to do that efficiently and did not think about the moral. “This inability to think created the possibility for many ordinary men to commit evil deeds on a gigantic scale. The sad truth is that most evil is done by people who never make up their minds to be good or evil". And that is -perhaps her most well known words - "the banality of evil".

Struck by the danger of thoughtlessness, Arendt spent the rest of her life thinking about thinking. Could thinking, she asked, save us from the willingness of many, if not most, people to participate in bureaucratically regulated evil like the administrative extermination of six million Jews? Only thinking, Arendt argued, has the potential to remind us of our human dignity and free us to resist our servility.

The ability to think is also an important issue in the field of ageing. Apart from the important issue of dementia, it could also be a kind of comfort to know that even if we have less years left, we at least will spend them knowing more about the world. Or that we are better able to cope with other people and not repeating our mistakes of the past. Unfortunately, most frameworks for ageing and health only look at issues like functional decline and frailty and make no distinction between physical and cognitive decline. We still do not know whether ageing means more wisdom and less muscles, nor whether the mind can compensate for some physical decline.

To answer these questions, I think it is important to first make the distinction between cognitive decline and the ability to think. Cognitive decline happens in the form of for example memory loss, lesser ability to play video games and dementia. It is true that this loss of cognitive functions can severely impact your ability to think (clearly). But in a way this loss is much more a form of physical decline (less cells and worse connections in your brain).

The ability to think is a deeper concept and goes much further than just the capacity to think fast and clear. It can be defined as the way to use experience and knowledge gained through the life course to come to deeper insights. The ability to think is not or much less connected to physical or even cognitive functions. By definition, the ability to think can increase over the life course, especially if you have experienced a lot and took the effort to gain knowledge. But not necessarily. There is also something which I call the wisdom paradox: young people are sometimes wiser than old people. The explanation is that those young have experienced more in their short lives and have already studied more than some their older fellow human beings who had more regular and superficial lives, mainly watching television in the evening.

But let's not be pessimistic and assume that most older people have gained some wisdom over the life course. Can old people use this ability to think for compensating some loss of physical functions? Maybe. I can think of not doing things that you better not do at a certain age. Especially men are vulnerable to the illusion that physical decline is something for others (I am no exception with my exhaustive biking up the mountain near Geneva this week on a sunny evening after work). Or to derive more pleasure from other things in life like reading and from the art of thinking itself. I think we need to explore this further and ask older people themselves to give us examples.

But how to compensate for the loss of cognitive functions that will have an impact on our ability to think? Memory loss is not something you enjoy and can compensate easily by doing other things in life. Fortunately, there are many new tools to help old people. LinkedIn wil help you remember the (names of) people you meet in your life, Outlook reminds you of your appointments and smart phones give you access to all information you need to have. While getting rid of the need to remember routine things in life, we can use our remaining brain power to really think when we are old. Well, hopefully.

Back to Hannah Arendt. She was a good philosopher but missed some important issues. Seldom I have seen a film where a woman was smoking that much. It is true that the dangers of smoking were less well known in her time, but a women with such an ability to think should have known better. Tobacco is evil and smoking is a banality. I am afraid that there are still many Eichmanns working in the tobacco industry.

 

Only God forgives

This week I saw the movie “Only God forgives” (or in Italian even nicer “Solo Dio Perdona”), an emotionally breathtaking, aesthetically brilliant and immensely violent thriller set amongst US expatriates in Bangkok. It is directed by Nicolas Refn, the Danish filmmaker who also directed the Pusher films and Drive. The story is about two gangster brothers in Bangkok. One of them, Billy, is killed after he murdered and raped an innocent girl and the victim's father revenges. The other brother, Julian, does not revenge his brother after knowing what he did. His inability brings two terrifying people into the movie: one is Julian's mother Crystal, the mafia Godmother, enraged at Julian's pathetic disloyalty. The other is the mysterious police officer Chang, who roams the streets armed with a sword: a sharia-samurai of justice. What follows is a deeply disturbing film with dream-like scenes of green light corridors, dragon heads, karaoke bars, torture, deep red blood and much death.

It is a bit of a transition, but death also features prominently in the World Health Statistics 2013 that were recently published. Did you know that every day about 800 women die due to complications of childbirth and pregnancy? And that 80% of deaths from malaria occur in just 14 countries? And that children in low income countries are 16 times more likely to die before reaching the age of five, than children in high-income countries? It can all be found in the publication and statistics at www.who.int/gho

One of the striking tables in the summary is about causes of death among children aged under five. In the first 27 days almost a third of deaths occur, most of them from preterm birth complications and birth asphyxia. Pneumonia accounts for a serious 18% of overall deaths under 5 and diarrhea for another 10%. In fact malaria (7%), HIV (2%) and measles (1%) are not even that big killers anymore for kids. 

There is also good news. The world has made progress in reducing child deaths by 40% from nearly 12 million in 1990 to less than 7 million in 2011. The number of countries where at least 1 in every 10 children die before their fifth birthday has more than halved, from 53 in 1990 to 24 in 2010. Many more children can still be saved with simple and cost-effective care.

In the World Health Statistics there is also information on causes of death in older people. They differ of course from the children, but are also quite different in the old age group itself, depending on how old you are. The very old (80+) die mainly from heart disease (in almost 50% of cases) and for the rest from cancer (13%), COPD (13%) and lung infections (6%). The not so very old (60-70) die also but less often from heart diseases (38%), more often than the very old from cancer (22%), less from COPD and lung infections and more often from the bigger group of other diseases. And obviously all elderly groups suffer much less deaths related to traffic incidents, violence and hiv-aids. On the good side, we can see from the statistics that life expectancy is increasing (worldwide from 64 years in 1990 to 70 years in 2010). And also that some countries are already pretty old (in Japan and Germany half of people are over 45). 

What do the World Health Statistics say about causes of death in Thailand? Is it really as terrible as is shown in the movie “Only God forgives”? Unfortunately, the tables do only breakdown by region and not by country. Looking at another source, http://www.worldlifeexpectancy.com Thailand is not doing better or worse on violence than other countries in the world. 

Of course also people experiencing death or violence are victims. I used one of the lunch breaks for a quick visit to the Red Cross museum that was reopened after a large renovation and modernization. It is more interactive now and you can walk around with an audio guide like in many other museums now. Interesting is that you can sit opposite to an eyewitness and hear his or her story. The tales are mostly about a natural disaster or genocide. Many people have experienced death or torture from a short distance. In some cases the guilty had to face trial, sometimes they escaped and sometimes they received forgiveness, like in South Africa. So not only God, but also people can forgive.

The contrast between listening to the consequences of violence in the museum (learning from violence) and watching a violent movie for fun cannot be bigger. I guess that eradicating violence from films and videogames is not possible and maybe not even desirable. However, it may help to put “Only God forgives” in perspective by visiting the Red Cross museum and by reading the World Health Statistics.