Sunday, April 26, 2020

What Does a Starfleet Captain Do in Retirement?



Jean-Luc Picard, the former captain of the Enterprise, retired to his family vineyard in France.  It is a beautiful setting and a quiet life for someone who previously explored the far corners of the universe.  Like many people who are retired, however, Picard looked back at his work and was troubled by the things he regretted and had left undone.  So when he is approached by a young woman seeking his help, he jumps back in to find redemption for a terrible set of events that he felt responsible for.

That’s the starting point for the new series, “Picard.”  It’s built around a prototypical retirement story, except maybe for the space travel and phasers.  The young people in Starfleet don’t want Picard back, and view him as a relic.  He can’t climb stairs or run any distance without getting winded, and he’s not up-to-date on the latest technology.  But with the help of some old and new friends, he throws himself into the midst of events that threaten the known universe.  A fun task for retirement.

Picard was always the most thoughtful and reflective of the Star Trek captains.  Captain Kirk would talk about the “Prime Directive,” which prohibits Starfleet missions from interfering with the development of alien civilizations, but which in the end Kirk often ignored.  Ethical dilemmas, however, were at the heart of many of the conflicts that Picard and his crew faced on the Next Generation series and play a prominent role in the new Picard episodes.  Luke Skywalker had a contrasting retirement, sulking on a remote island seeking enlightenment that he didn’t seem to have found.  Where the Star Wars franchise has relied on special effects and cartoonish battles to make up for a lack of new ideas, Picard has gone forth boldly, though a bit more slowly than in the past.  He’s not an action hero.  Rather, he is a wise person who has an unfaltering understanding of the importance of doing the right thing.  It helps that Patrick Stewart, who plays Picard, is such a fine actor.  

The series has been great fun to watch, a nice diversion in our current dilemmas.  I’m now enjoying the other new Star Trek show, Discovery.  It’s entertaining, though you have to get past the first two episodes.

And if you are really serious about Star Trek, and who isn’t, I just read that Tribbles are available on e-Bay.




Friday, April 17, 2020

Covid-19 Deaths in Nursing Homes: Why It Is Important to Consider Causes and Solutions

Sunset over Lake Vattern in Sweden

This headline in yesterday’s Washington Post caught our eyes: “Covid-19 is ravaging nursing homes.  We’re getting what we paid for” (see link below).  There’s no question that clusters of infections and deaths have been common in nursing homes across the country, as well as other countries such as the UK where statistics on prevalence of Covid-19 has been reported.  Half of the deaths in Pennsylvania have been among nursing home residents and staff.

We should not be surprised.  Nursing home residents constitute the most vulnerable group in society.  But it’s not just that residents are old and frail.  Rather, the articles we have seen report that the nursing homes and assisted living facilities that had clusters of cases did not take the steps needed to protect residents and staff.  We want to be clear that there are excellent, well-run residential facilities for older people that have done a good job of protecting residents and staff.  The point raised in the Post article is that inadequate funding for nursing homes is a long-standing issue and so it should not be surprising that there are deficiencies in responding to a crisis like Covid-19. 

Nursing homes are not the only problem area.  The Covid-19 crisis has revealed many weaknesses in our health and public health infrastructure.  Federal and state governments have spent the last few decades cutting back public services and investments in health, education and most everything else.  With all the people who still have no health insurance or lost their insurance when they lost their jobs, it’s clear that we need universal health care.  We also need the state and federal government to have the infrastructure to respond in a crisis, for example, with more efficient ways of delivering unemployment benefits.  And then there is testing and tracking of the virus.

But once the crisis is past and there are discussion about building our infrastructure, let’s not forget long term care. The US alone among economically-advanced countries has no program of universal long term care.  Instead, we have a rickety system of funding.  People who can pay privately for care can often, but not always, receive good care.  But the typical nursing home that depends primarily on Medicaid will, despite good intentions, struggle to provide a high quality program.  

Here is a modest list of what we need, or at least where to start.

1.     Along with discussions of universal health care, we need to advocate for a national program of long term care insurance that will assure that people get good quality care when they need it.  We could follow the model instituted in Japan and South Korea, where the tax funding long term insurance goes into effect when people turn 40.  That way, the tax burden does not fall on young workers, who tend to have lower earnings.  And by 40, most of us have realized we may need to help aging parents, and indeed, that we may need help for ourselves.

2.     Long term care programs, and indeed, all of health care, should be run either by government or by non-profit organizations.  Simply put, when there is a choice between paying for improved care or maximizing profits, it is too easy for administrators and owners to cut corners that improve their bottom line.  We have seen that happen over and over.  Some of the worst clusters of Covid-19 have been in for-profit nursing homes.  They didn’t pay for adequate staffing or for taking the steps to protect residents and staff.  When owners of these programs have been identified by the press, they often hide or refuse to comment.  

The perversions caused by using a business model that prioritizes profits over care affects all of health care.  With nursing homes, however, the effects are particularly pernicious because residents are the least able to advocate for themselves and because we have such low expectations for quality of care.

3.     We need stronger programs for helping older people remain at home.  Almost no one wants to end their life in a nursing home.  But while we have given lip service to supporting people to remain at home, the system of community services remains fragmented and inefficient, and workers are typically poorly paid and trained.  All-too-often, community service agencies make excuses instead of delivering the type of help that people need that will keep a frail person at home.     

4.     The people who work in aging services need better training.  We have each been in this field for over 40 years, and it is frustrating to say that we have not made much progress in training the front-line people better.  Everyone from administrators to nurses to the aides that deliver the care needs specific training in aging and long-term care.  All too often, the training people receive involves how to meet various state and federal requirements and not how to provide optimal care.

In the US, a certified nursing assistant receives 75 hours of training.  By contrast, in Sweden where nursing home care as well as community services are generally quite good, care assistants (vardbiträde) receive one year of training, and nursing assistants (undersköterska) complete three years training.  Pay is not great, but it is relatively better than in the US, and everyone—employees and their families—are covered by the Swedish national health care.  As a result, they can live on their salary.  Workers can also gain the training needed to move up, from care assistant to nursing assistant to nurse.  Tuition is free. We saw one recent article that proposed extending the GI bill education benefits to health care providers working with Covid-19 patients. That would be quite a nice step forward.

5.     The best facilities we have visited over the years in the US has someone in charge, either the administrator or director of nurses, or both, who has a vision of what good care means.  They pay attention to the details of everyday care, and make sure that all staff share the same values around good care.  We need to find more people like that, reward them, and make sure their voices are heard. 

There are likely to be shakeups in how we do things in this country, once the immediate crisis diminishes.  We need to make sure that long term care gets included in the discussion.  

Reference:  

Saturday, April 11, 2020

Missing Baseball



Sitting mostly at home these days, I found myself wishing that there was baseball.  Baseball is the perfect sport for when you have lots of time on your hands.  The slow pace doesn’t matter.  I remember a time when I was in graduate school and had a bad case of the flu that kept me in bed for more than a week.  I looked forward each day to the radio broadcasts of the White Sox games.  Win or lose, it brightened the day.

In the absence of real games, I decided to watch my favorite baseball movie, Bang the Drum Slowly.  It doesn’t make most lists of favorite baseball movies, but I find it captures more of the essence of the game than films like Field of Dreams that romanticize the game.  The movie was released in 1973, but it was based on a book written by Mark Harris in the 1950s and has the feel of an era before baseball became big business.  The movie stars a young Robert de Niro who gives a terrific performance as a back-up catcher who has a terminal disease.  The team’s star pitcher (Michael Moriarty) tries to help him hide the illness and stay on the team.  Despite the serious theme, the movie is often quite funny.  The pep talks given by the manager (Vincent Gardenia) are hilarious, as is much of the banter among the players.  

In the end, the movie quenched my thirst for baseball, at least temporarily.  It felt like baseball.  The players faced real dilemmas that teams encounter during a pennant race.  With, of course, one major difference, a teammate who was dying.  The players responded with an awkwardness you would expect from young men and but also with sensitivity.  Maybe it’s a movie for our times. Or at least to enjoy baseball for a couple of hours.

Saturday, April 4, 2020

HIGH RISK!

In Marrakech airport  

During our stay in Morocco, one of the emails we received from the US Embassy asked us to register with the embassy so they could contact us. They also asked us to indicate if we were at high risk for COVID-19. After looking at each other for a minute, we realized we are at high risk by our age. Although the embassy did little to help in the end, it did change how we think about ourselves.

Since coming home, our “high risk” designation has been reinforced. Every communication in the media emphasizes that we should take extra precautions. Food stores are creating “senior hours” where we can shop when there are fewer people in the store. One of our friends, however, warned us that lines form outside before the stores open, but we have not
encountered lines.

Being considered high risk comes as a shock. We are used to thinking of ourselves as healthy.  After all, we lead active lives. We exercise daily and travel to exotic places like Morocco. Yet there it is—high risk. The label conveys in a very tangible way the consequences of our age. But we are adapting. Gyms are closed so we take 3 walks a day around our community. Lots of our neighbors, young and old, are out, too, and we all say hello but keep the appropriate social distance. We restrict our trips to stores to a minimum. 

\We discovered an unexpected treasure the other day, discovering that we could buy tissues and 4 rolls of toilet paper at our local pharmacy. Who knew that buying toilet paper could be exciting?  We have decided it is important to help our neighborhood restaurants during the crisis by ordering take out on a regular basis. On Monday, it was soup dumplings and pot stickers from Everyday Noodles. Then, it was croissants and sandwiches from La Gourmandine Bakery. Next, some excellent Thai food from Silk Elephant. This really seems “win-win.”

The hardest thing about being high risk is not visiting our two grandchildren who live here. Our daughter-in-law is a pediatrician who works in a hospital and could be exposed to the virus. As “high risk” people, we need to avoid any place we might pick up the virus. So far, we are doing Face Time, and hoping for a quick resolution, though we suspect COVID-19 will be around for a while.

We would feel better about the situation if the government had an organized approach to the
crisis. Our governor has taken positive steps but the federal government has dropped the ball on marshalling resources needed for medical care and protecting people from the virus.
There are people who see the whole picture and know what we need to do, such as Anthony Fauci and Ezekial Emanual, who wrote a terrific column the other day (see the link below).
We received a terrific video from our friend, Elia. The video was made by Dr. David Price, a
pulmonary specialist at Weill Cornell Medical Center in New York City. Dr. Weill, who has been providing care to the COVID-19 patients in his hospital, discusses how the virus is transmitted and how the steps he proposes will reduce risk. He also discusses what to do if you begin developing symptoms. We highly recommend the video and have provided a link. It made us feel that maybe we are not at such high risk after all.  Of course, in light of new information in the past week, some of what Dr. Price says has to be modified (the part about aerosols). And now we are wearing face masks whenever we go out. 

There was also an excellent editorial in the NY Times by James Baker that lays out the steps that need to be taken to lead us out of this.  




Link to Dr. Price’s video: 
https://www.youtube.com/watch?v=WxyH1rkuLaw

Link to the column by Ezekial Emanuel:
https://www.nytimes.com/2020/03/23/opinion/contributors/us-coronavirus-
response.html?action=click&module=Opinion&pgtype=Homepage

Link to the James Baker editorial:  
https://www.nytimes.com/2020/04/03/opinion/defense-protection-act-covid.html?smid=nytcore-ios-share