On being Very, Very Old: An Insider's Perspective

Elaine M. Brody, MSW, DSc (Hon)

Disclosures

Gerontologist. 2010;50(1):2-10. 

In This Article

Past Perspective

My formal career in and past perspective on gerontology began in 1957 when I was first employed at the Philadelphia Geriatric Center (PGC). My husband Steve (Stanley J. Brody) encouraged me to go to graduate school while he was in the Navy during World War II. When the war was over, I followed the traditional path most women took in those days, becoming a homemaker and raising our two children. When those children were of school age, I took the only part-time job I could get that was close to my home. It was at the PGC. I was hesitant because I had trained to do psychiatric work with children. Art Waldman, the creative genius of PGC, persuaded me to try it. He said, "If you don't like it, you can leave and no hard feelings." I tried it, I liked it, and I never looked back. It was the only place I ever worked, but because the PGC was constantly changing, it always felt new. (Actually, I ended up working with parents and children as I had planned, though the parents were old and the children middle aged.)

On my first day at work, I was given a spacious but windowless office in the basement next door to the morgue. But it was at lunch that I really began to learn about the ailments of the elderly adults. In the small staff dining room, Jerome, the elderly waiter, asked me, "What do you want to order?" "What do you have?" I countered. He replied, "We have diabetic, ulcer, salt free, gall bladder and regular."

At that time, the agency was a 150-bed home for the aged and, like similar facilities everywhere, was mandated to care for the "well aged." Such facilities were the descendants of the poor houses of yore. Most of those being admitted were in poor economic circumstances and had few expectations of environmental amenities. Some of the elderly men assumed that the air conditioning vents were urinals, with expectable unfortunate consequences.

I was assigned to do "intake" of the individuals on the long waiting list for admission. The routine medical screening examinations were finding most applicants to be ineligible because they were not "well." At the same time, the number of "well" applicants was shrinking.

What was happening was that at that particular time, a process of significant change was under way: A series of developments that began in the 1920s were converging to create dramatic changes for the aging population and therefore for the population as a whole.

First, older adults were not only increasing rapidly, numerically and proportionately, but their health characteristics were also changing. As you know, breakthroughs in prevention and treatment of the great epidemic diseases were allowing more people to grow old and very old. Therefore, they became vulnerable to the chronic ailments that Gruenberg (1977) called "the failures of success."

Another significant process was a series of socioeconomic developments, such as Social Security, Medicare, Medicaid, and Supplemental Security Income. These programs had been propelled into existence by the Wall Street crash of 1929. I was 7 years old at the time of that crash, and I remember the Great Depression well. Those memories caused an almost visceral reaction to the current economic crisis in those of us who are now 85 years or older and experienced that grim period firsthand. The reports of despairing men jumping out of windows; three-generation families, including those of our friends and relatives, moving in together because they could not afford to live in separate households; two in five Americans jobless. There were bank closings, farm foreclosures, and family migrations across the country to find work. It was a massive disaster.

President Franklin Roosevelt set up a commission, and Congress enacted the Social Security Act in 1935. The Act did not create an income floor all at once, of course. It took many years for it to do what was intended. As it phased in, fewer and fewer older people lived in poverty, though too many still do.

That impetus given to social policy development is what my husband Steve Brody (1987), in his Kent Award lecture, labeled the "catastrophic approach" as the response of social policy to economic catastrophe. Thus, the Social Security Act responded to the catastrophe of the Great Depression and the need for the government to provide basic subsistence. Before Social Security, more than half of all people aged 65 years and older were totally dependent economically on their adult children, and another 25% were dependent on Public Assistance Programs. Harsh regulations enforced adult children's financial contributions toward the support of their elderly parents. Social Security gradually took hold (together with private pensions). What a difference it made! By 1980, only 1.5% of the old were totally dependent economically on their children, though poverty was still widespread.

As Steve pointed out in his lecture, 30 years after Social Security, Medicare and Medicaid responded to a "second catastrophe": the resources of entire families were being depleted because of paying for medical care for older people. Some of you may remember, as I do, the neglect that previously had been suffered by poor older people before Medicare: the six or eight bed wards in hospitals, the humiliating outpatient clinics with 50 or so people waiting to see a doctor, families giving up vacations, and children wearing worn hand-me-downs and foregoing many amenities.

Social Security, Medicare, and subsequent legislation benefited not just old people but all generations. These government programs were followed by the invention, development, and funding of facilities and services for the older adults, beginning with the Older Americans Act in 1965. Previously, the help the adult children gave to their elders often resulted in severe deprivation of Generations 2 and 3. When old people need help, the domino effect disadvantages the younger members of the family.

Still another process that occurred was the explosion of professional and scientific interest in aging. In December 1945, the Gerontological Society of America (GSA) was formed with 23 members. By the time I became President of this organization in 1980, membership had increased to 5,581. Practice, as well as research, was developing rapidly. I am glad that we have maintained our strong interdisciplinary approach and our emphasis on the essential partnership between research and practice. Those principles were central to M. Powell Lawton's creed. Anthropologists, sociologists, social workers, physicians, nurses, psychologists, architects sat around the same table to contribute their insights.

Friedan's (1963) book, The Feminine Mystique, was published, creating a sea change in women's lives and triggering their rapid entry into the work force. Many women (the main family caregivers to the old) took on the additional role of out-of-home work. Middle-aged women entered the work force at a faster rate than any other age group. This process contributed in turn to the phenomenon of the overburdened and stressed women I called "women in the middle," who were my main research interest for many years. Ironically, many who responded to Friedan by going to work were forced to quit their jobs to care for an older person in the family (Brody, 1990).

The net result of those developments was a change in the characteristics and needs of older people as viewed through the lens of the PGC's applicant list: Our applicants were chronically impaired, not "well." Their ranks were increased by those with Alzheimer's disease who were being discharged from state hospitals with the benevolent rationale that they were being sent "back to the community." Some of our applicants were being enabled by Social Security to live in their own homes and avoid institutions. But social, as well as medical, problems often forced applications. Applicants who were childless and widowed had fewer family supports to help them live in the community. Or they had "old" children who were sick or who had died. Those who had no family were exemplified by the elderly man who, when asked why he sought admission, replied simply, "I am an orphan."

All those developments together—demographic, legislative, scientific, economic, and social—combined at that point in time to cause dramatic changes in the lives and care of older people. At the same time, the pool of physically and/or mentally disabled old people in the community who needed a care facility was growing rapidly.

Convinced that our admission policies at the PGC were outmoded in accepting the "well aged" and rejecting the "impaired aged," I lobbied Art for change. He gave me permission to follow-up the people who had been rejected to see what had happened to them.

That was my first "research" study. Though I knew little of sophisticated research methodology, I designed a questionnaire so that I would have comparable information about all the old people we rejected in the previous year. After interviewing all of them, I pushed back the furniture at my home; spread out all the data sheets on the floor (this was decades before the advent of personal computers); and did correlations by walking around the room, picking up the appropriate papers, tallying them, placing them back on the floor, and then going on to next variable (Brody, 1966b). I could not do all that bending today.

I found that some of our rejectees had died, some were living in the homes of severely stressed and crowded families, and some were being neglected in "boarding homes." Art used my report to persuade our Board of Directors to relax our admission criteria gradually—a policy that quickly gained momentum. Ultimately, we not only accepted impaired and disabled old people but also invented and developed special programs and facilities with different levels of care for different groups. Over the years, we grew from the original 150-bed facility to a campus that housed and cared for 1,400 older people in different kinds of facilities (apartment buildings with services, a fully accredited geriatric hospital, a special building for Alzheimer's patients, assisted living, outpatient diagnostic services, etc.). We served thousands more who lived in the community. (For more complete description of the PGC, see Brody, 2001.)

A year after my follow-up study, Art Waldman lured Powell Lawton to the PGC to create a Research Institute. (Whoever heard of a research unit in a home for the aged?) He was given various documents including my follow-up study in order to orient him to our facility. Walking into my office with my report in hand, he asked, "Where did you send this for publication?" "Nowhere. It was an in-house study," I replied. Powell said, "Publish it!", so I did and moved rapidly into research.

That study and Art Waldman's ensuing actions were valuable lessons to me in the translation of practice into research and back again into policy and practice. In social work school, I had been taught to "listen" to the meanings behind the words communicated by my clients. When I did research studies, I thought of research as "organized listening." I often used both kinds of listening in research studies to follow, using a qualitative study to precede the quantitative research so as to identify the issues to be included in the survey questionnaire.

Thus, in my past perspective, there was a time when almost nothing existed to benefit older people, but "the curve was in the right direction." It was an amazing few decades. And I was growing old, though I was not really aware of it.

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