Study Commens

Week 13 Comments – Chapter 14 – Elders of Color

Chapter 14 – Elders of Color (we are also doing Chapter 15 this week, which is below) Pp. 525-526 – Heterogeneity As the book notes, if you are older and either an ethnic minority or a woman (or both), you will likely experience a very different environment and life course than if you are a white male. There are, of course, cohort effects in place here, too. An older black American today has a different experience than an older black American had fifty years ago, and most likely an older black American fifty years from now will have another different experience. Groups that are “homogenous” are similar in key ways; groups that are “heterogeneous” are different in key ways. The roots are “homo” (same) and “hetero” (different). Older adults as a group are NOT homogenous – they differ widely based on color, sex, ethnicity, income, health, education, and numerous other variables. Many of the negative experiences ethnic minorities have in older age are due to their earlier lives. A lack of education leads to less employment or lower wages. Lower wages translates into lower Social Security benefits. A poor diet and lack of access to health care in childhood or young adulthood can mean more chronic medical conditions (such as high blood pressure and diabetes) at an earlier age (in the 40s rather than the 60s or 70s). Pp. 526-527 – Ethnicity / Minority / People of Color The book defines ethnicity as having a distinctive social and cultural heritage; as having a certain social status (or lack thereof); and of having certain kinds of support systems. People and agencies who work with non-white clients must understand the different social and cultural views in everything from family interaction to medical intervention to communication styles. They must also consider what a lifetime of low social status might mean to a person, and how their informal and formal support systems operate. A failure to do this almost always results in poor outcome and frustration for all parties. Pp. 527-529 – Defining Minority and People of Color Everyone is “ethnic,” but not everyone is a minority (basically, in North America, non-white), and not every minority is disadvantaged (on average) compared with the majority (on average). Also, in some places, groups that are considered “minority” when looking at the total US population, are actually in “majority” status. Thus, the use of the phrase “people of color” has evolved. The idea here is that ethnic status sets you apart from others and influences the course your life takes, whether negative or positive. As the book notes, people are often “labeled” an ethnic minority based on such characteristics as language, physical characteristics, and cultural characteristics; AND from the experience of prejudice and discrimination (“differential and unequal treatment,” part of a “distinctive history”) due to their race, which causes an attachment among members. The focus of this chapter is on groups of people who have been discriminated against or oppressed because of their race (ethnicity) and how that history of discrimination / oppression influences those groups in older age. (Notice it is looking at groups, not necessarily individuals; there are always exceptions.) Just as older people as a group are not homogenous, members of an ethnic group are also not homogenous. “Latino” can refer to people from Mexico, Puerto Rico, Guatemala, Colombia, the Dominican Republic, Cuba, Argentina, and so on. It can mean, interchangeably, a person who left Puerto Rico two years ago and now lives in a crowded apartment in New York City AND a person whose great-great-grandparents were from all Mexico and who lives in an ocean-front home in Santa Monica. The two probably have NOTHING in common with each other. African-Americans can include people literally from Africa who came to the US last year, a 7th-generation custodial grandmother living in a housing project in New Orleans, and a 7th-generation retired engineer in a Seattle suburb – none of whom have anything in common with each other, either. Native American groups are even more heterogeneous. So, when we discuss ethnic groups, we are looking at aggregates, not individuals. There will be LOTS of exceptions! Pp. 529-530 – Why Gerontologists are Interested As the book notes, gerontologists are particularly interested in the role of ethnicity because people of color are more likely to require social services than white Americans. (However, white Americans receive, by far, the most social services, simply because there are more white Americans. Non-white Americans are merely more likely to require social services.) Also, the success of such services is impacted by different expectations, attitudes, etc. that are associated with ethnic background. So, to ensure effective delivery of social services, gerontologists need to understand the cultures, values, beliefs, and historical experiences of different ethnic minorities. This has led to the rise of ethnogerontologists, who study the causes, processes, and consequences of race, national origin, and culture on individual and population (group) aging. Skip ahead to p. 532, on black Americans. Pp. 532 – Older African Americans Just notice two things here – the higher mortality rate among younger black Americans means there are fewer older black Americans, and socioeconomic status is an important mitigating factor. P. 533-534 -- Black Americans’ Economic Status Notice that the poverty rate among older black Americans is triple that of older white Americans. (However, there are MORE older, poor, WHITE Americans. Don’t confuse rate / likelihood with actual numbers. If I have 1000 white Americans and 10% are poor, then I have 100 poor white Americans. If I have 100 black Americans and 30% are poor, then I have 30 poor black Americans. The black Americans are three times as likely to be poor, but there are still far more poor white Americans.) This increased poverty rate is explained in the bullets on p. 533. Notice how three of them refer to ongoing issues in their younger adult years – limited employment, low-paying jobs, and limited pension income (because the jobs they had in their younger years didn’t come with pensions). Some of that is due to the first bullet, lack of education. Notice how the “retirement due to health problems” is also most likely related to on-going diet and exercise patterns, and/or increased wear-and-tear, and possibly insufficient health care, in their younger adult years. The point is that these things accumulate. I am reminded of one young man I knew in the mid-90s who dropped out of college because a friend wanted him to join him in a landscaping business. He would make $10 an hour, which is about $20,000 a year. No benefits. I was unable to dissuade him. (He happened to be white, by the way.) This kind of decision just sets the stage for all the variables described above – limited employment (you are dependent on the weather, for one thing, and also on the whims of your employers, meaning the people who hire you to trim their hedges – they could move, or have a change in finances and cut your service); low-paying ($10 an hour is not much, and it’s not likely to go up by much, either – there are always other, younger, people who will do the work for that same $10, so your wage is pretty much frozen); and of course no pension because there are no retirement benefits. There are also no health benefits, so should a health condition come up, you may ignore it, or treat it on the cheap, thus setting the stage for more health problems down the road. Also, landscaping can be hard, physical labor, and you may not be able to continue it after age 50 or 55, thus having to retire early. This kind of experience is quite common among black Americans. The book notes that black Americans spend a greater proportion of their lives working. They also spend a greater proportion disabled, which sounds sort of contradictory. But black Americans (at least of the current older cohort) often started full-time labor at age 10 or 12, and even when disabled may be forced to work at extremely menial jobs for financial reasons, which just exacerbates their health problems, leading to an earlier death. So, if you work from ages 12-68, and die at age 68 of work-related health problems, you have spent 82% of your life working (56 years out of 68). If you work from ages 18-65, and live to 75 (the more typical white worker, with a high school education), you have spent only 62% of your life working. (Now, imagine you are white-collar, and work from ages 22-60, and live to 85 – it’s only 44% of your life!) Pp. 534-536 – Health Notice that the biggest factor affecting the higher mortality and chronic disease rates in black Americans is economic status. Older black Americans are far more likely than older white Americans to live in poverty or near-poverty. (But, again, most poor older Americans are white.) However, in addition, there are also impacts based on prior discrimination in health care -- having to wait in the emergency room until all the white patients have been treated, for example, or white doctors refusing to treat black patients, not to mention the Tuskegee Institute studies on syphilis that resulted in widespread distrust of medical institutions among many black Americans – see my comments below. Black Americans are more impacted by particular diseases than white Americans – namely, hypertension (which leads to stroke) and cancer (which is still a “taboo” word among many black Americans). Obesity, which is linked to diet and exercise (and poverty), is more prevalent among older black women in particular. Discussion Question #1: So, given all of this – if you are a gerontologist designing a community health program for a predominantly black community of older adults, what are some things you could / should do to better serve them? (The Tuskegee studies: A number of black men who tested positive for syphilis were not given treatment (nor told they had syphilis), on the grounds that there was no research on how syphilis manifests itself in black people, and it would be “useful” to follow the “normal course of infection” and manifestation in a black population, blah-blah-blah. This is so incredibly highly unethical that words do not exist to describe the fall-out that resulted when the study became public FORTY years later. I should note that “infection” referred not only to the women who were the men’s current or subsequent sexual partners, but also to the children the women gave birth to who were at risk of also contracting syphilis, from their infected mothers. Syphilis is a particularly nasty disease that essentially attacks the brain wherever it wants, leading to numerous symptoms ranging from delusions to memory problems to speech difficulties to blindness to you-name-it. You do not EVER want to get syphilis. Winston Churchill’s father died of syphilis and it was not a pretty several years. Fortunately, it can be treated today IF caught early enough. Here is a really interesting website that gives lots of information about the study: http://www.infoplease.com/spot/bhmtuskegee1.html. I have also copied it into its own file -- you do need to read it – in case the link doesn’t cooperate. I will also note that, fortunately, syphilis is contagious for only about a year, so mercifully the damage was somewhat minimized, in terms of infectious spread.) Pp. 536-538 – Social Supports and Living Situations Older black Americans benefit, compared with older white Americans, from a larger and closer extended family, which provides much care and social interaction for the older members. Their families and households are more likely to expand and contract depending on the needs of extended family; it is not unusual for three or four generations to live in one flexible household, with family members moving in and out as financial and other needs demand. It is also not unusual for extended family to live in close proximity – four or five households on one block, for instance. This tends to increase closeness beyond the usual three generations – e.g., third and fourth and even fifth cousins are just as close as first cousins. In addition, black Americans are the most likely to include fictive kin in their extended family. Fictive kin is anyone who is treated as a family member. It could be your dear friend’s grandson, a family from church, neighbors, etc. In many black churches, members are referred to as Sister This or Brother That (or Aunt This and Uncle That by younger children) thus blurring the lines between fictive kin and “actual” kin. The book notes that black Americans have a broader range, not just a larger number, of potential caregivers. A white person may have six children and fifteen grandchildren (only half of whom live within an hour’s drive), but a black person may have all of them plus thirty more fictive kin and “distant” cousins, ALL of whom operate as close family members, and most of whom live within a five-minute drive. Note the list of reasons why black Americans are less likely to move into nursing homes. The “racist practices” one is unfortunately true even today. Nursing homes are at liberty to allow people in when there is space available. It is not unheard of for them to not have any space available when a black person’s name comes up. In some cases, they fear that other residents (who are white) will move out, if they allow black residents to move in. (One hopes this is a cohort effect in the case of the white residents. In one of the HUD apartments my grandmother lived in, a black woman moved in across the hall and down one. My grandmother was always polite to her – “Good morning,” and a nod of the head – but it took her years to have an actual conversation with her, and even then it was about the weather or some other impersonal topic. So stupid. I suppose I should take heart that, overall, society has greatly improved in the last 40 years.) Pp. 538-539 – Older Latinos Note the great diversity, mentioned previously. Notice also the lack of statistics on the number of Latinos, due to the fact that census forms (in the past) had categories for Black, White, and Other (see. p. 531). Some Latinos considered themselves black, some considered themselves white, and most considered themselves “other,” which lumped them in with the Asians and Native Americans and all the other “others” until the census bureau finally wised up and expanded the category choices. (This was also true, of course, for the Asians and Native Americans and so on, who were lumped in with the Latinos, etc.) P. 540 – Economic Status The biggest issue for Latinos, versus black Americans, is the language barrier if they don’t speak English. Virtually all black Americans do speak English, but large numbers of Latinos do not, which creates all kinds of implications for delivery of health care, public service announcements (which should be in Spanish if they are going to reach a Spanish-speaking population), potential misunderstandings, etc., which we will get to later. Another huge issue for Latinos, versus black Americans or any other ethnic minority, is that a significant number is in the United States illegally, which means even if they have worked for 40 years and paid into Social Security and Medicare, they are ineligible to receive benefits from either. (They also are ineligible for Medicaid.) Similar to black Americans, Latinos have traditionally worked at low-pay, non-pension-paying jobs with no health benefits. About 55% of older Latinos Americans live at or near poverty (compared to 30% of older white Americans). Pp. 540-542 – Health Similar again to black Americans, Latinos’ health is affected by years of poverty (which leads to poor nutrition), of hard physical labor, and of poor health care. Their “physiological aging tends to precede their chronological aging.” In addition, their greater tendency to work in agriculture has meant greater exposure to pesticides. They have not been directly affected by the Tuskegee study, but the language barrier and a reliance on folk medicine and religious healing, and a general suspicion of white culture, means many older Latinos do not receive adequate health care. Pp. 542-543 – Social Supports and Living Situations Latino families are similar to black families in terms of having large, close extended families. They are different from black and white families in terms of gender roles, partly influenced by the role of the Catholic Church. “Family” tends to be extremely important to Latino individuals, who typically place family needs ahead of individual needs. This can be good and bad, as you might imagine. On the one hand, a woman may move in with her grandmother to provide care for her for two weeks while the grandmother recovers from surgery, but in the meantime her own two kids are missing school because they’ve moved with her. This devotion to extended family often conflicts with traditional “white” American society, which focuses on the nuclear family and moves the extended family to the periphery. The values of “marianismo” (named for the Virgin Mary) tend to place women on an exalted pedestal in terms of morality and sexual purity, but also to expect women to endure suffering without complaint. Among other things, an effect of this is the strong disapproval in the Latino culture for remarriage by widowed women, who are expected to mourn their deceased husbands for the rest of their lives and live a completely celibate lifestyle, devoted to maternal nurturance of grandchildren. “Machismo,” or the belief that males are the heads of families, have special privileges, and do not perform “women’s” roles, also strongly influences many Latino families and individuals. For one thing, it leaves many Latino men rather helpless if their wife dies, as they are unable to perform many domestic tasks (e.g., cooking, laundry). (It’s not that they can’t physically do it, but a lifetime of belief that such tasks are beneath them makes it extremely difficult, psychologically, to teach them how.) Being the family’s provider (monetarily) is also a component of machismo, which can make retirement more difficult for some Hispanic men, as they no longer have that role. Both machismo and marianismo are similar to the Victorian ideals of separate roles for the sexes. Both are also most likely cohort effects, at least to some degree. Discussion Question #2: If you have any examples of health care issues, extended family / fictive kin as related to older black or Latino Americans, or marianismo or machismo as related to adapting to older age, please share them. Pp. 543-54 – Older Native Americans Notice the extreme diversity of Native Americans – over 500 tribes; people living on reservations and off reservations; and almost 300 languages. Notice also the presence of the Indian Health Service – unlike black or Hispanic (or Asian, etc.) Americans, Native Americans do have a federal agency focused on their health needs. P. 544 – Economic Status Native Americans are the poorest segment of American society. Because of a combination of low education levels, low income from reservation employment (assuming there is reservation employment to be had), and lack of retirement and medical benefits, many older Native Americans have a spotty work history, numerous health problems, and little income. While a few tribes have benefited financially from casinos, the vast majority of Native Americans has not. PP. 544-547 – Health Notice that Native Americans have the poorest health of all Americans, in addition to being the poorest financially (as a group). The two biggest health issues for older Native Americans are diabetes and hypertension, both of which are related to obesity, which seems to be related to the sudden adoption (in a large population) of a “white” diet (processed foods, fatty foods, etc.). A number of Native American tribes are attempting to return to a traditional diet, in hopes of stemming obesity and diabetes and other related health issues. Modern American health care is almost diametrically opposed to traditional Native American ways of healing, which causes many Indians to avoid “white” providers of health care. For decades, the IHS did not allow traditional healers and medicines to be used in its facilities, but that has fortunately changed. Now, many health care providers combine traditional treatment with modern practices, which has shown positive results. The book notes that Native Americans tend to be physically older than their chronological years, which creates a problem for someone who is, say, 55 chronologically but has the health problems of a 70-year-old, and is not eligible for Medicare (which kicks in at 65). Strict, age-based health-care regulations work well for white-collar, middle-class Americans, but not for those whose lives have been marked by poverty and / or physical labor. Unfortunately, given the burgeoning expenses associated with Medicare, that age limit is not likely to be lowered for any group any time soon. Other issues affecting health care include: 1) isolation (living on remote reservations, literally hours from any medical facility) 2) a lack of transportation, even if medical care is relatively close (this is often linked to poverty) 3) a mistrust of non-Indian health care providers (similar to many black Americans), based on a history of unethical practices by white Americans over several hundred years 4) taboos related to certain words or actions that prevent individuals from either discussing symptoms or following medical instructions 5) living in cities that do not have IHS clinics (which are primarily on reservations) 6) an emphasis by the IHS on services beneficial to younger adults and children, and acute (not chronic) care 7) a lack of IHS nursing homes (only ten in the entire country), which means an older Native American will most likely have to move very far from family and a familiar environment plus the others in the book. P. 547 – Social Supports and Living Situations Notice in the paragraph above (in the book), the BIA’s land-grazing policy. The basic issue is that, in the past, an older Indian could receive supplemental financial assistance at a certain age, while continuing to graze sheep or whatever. This way, they were still doing productive work (and thus seen as a contributing member of society), but could also supplement their (meager) income, which of course included rising expenses associated with health care. But then the BIA decided, no, you can only receive the supplement if you no longer use the grazing privilege, which you now must transfer to your heir(s), meaning you no longer are contributing productively AND you have a smaller income. So, now you need more social supports. Notice that a large majority of older Native Americans lives WITH extended family. This is very different from white or black or Hispanic elders. (Black and Hispanic elders tend to live very NEAR family, not “with.”) One issue for Native Americans that other ethnic groups do not face is the dispersal of family members between urban areas and the reservation. If an older person has always lived on the reservation, but all of their adult children now live in, say, Phoenix, and the older person needs care, he or she may have to leave the reservation and move to Phoenix, which can be extremely stressful. (A similar situation has existed in the past with black Americans who left the south in the 1940s and 1950s to seek work in the factories of the north; their older relatives generally remained in the south and so providing care for them could also be tricky. Most of the parents of those adult children who moved north have died, so that is not such a big issue now for most black families – another example of a cohort effect.) Discussion Question #3: If you have any Native American older-adult stories to tell – difficulties or positive experiences with IHS, cultural beliefs that hindered or helped care, reservation vs. urban issues, etc. – please share them. file:///F|/Documents%20and%20Settings/Justin/My%20Documents/School/Spri...20on%20Aging/Section%204/Comments%20on%20Chapter%2014%20(week%2014).htm (1 of 2)5/4/2007 4:39:56 AM

Week 13 Comments – Chapter 14 – Elders of Color

Pp. 548-554 – Older Asian Americans and Pacific Islanders Given that there is some overlap among all ethnic minorities, I am only going to focus on a few specific points in these pages. 1) there is little information on older Asian Americans, so this will be spotty 2) lots of diversity again (Chinese, Vietnamese, Korean, Japanese, ...; immigrants vs. 5th-generation; urban vs. rural; etc.) 3) a number of discriminatory laws passed by the US government, including the internment of Japanese-descent US citizens in camps during World War II (that one still blows my mind), and how can you deny CITIZENSHIP to people who are BORN HERE??? Not to mention the antimiscegenation stature (forbidding Asians to marry white Americans); all of this leads to a distrust of the government-based medical system 4) Asian Americans are considered a “model minority” (due to high levels of success among many but certainly not ALL Asian Americans), which means their problems are trivialized or overlooked entirely (there are many older Asian Americans living in poverty, with no Social Security or retirement benefits) 5) an emphasis on hierarchical social status (you don’t associate with those “beneath” you – think of India and the caste system, an Asian example, although pre-WWI England also works) – this means they won’t / don’t seek assistance from those whose social status is unclear, or from government agencies 6) there is a general unwillingness to discuss or acknowledge health issues 7) the law of primogeniture states that the oldest son (or rather, his wife) will provide the care for the parents, which is contrary to what typically happens in America, and may not be embraced by the oldest son (or his wife). Pp. 554-557 – Implications for Services Note that services are not used as much by ethnic minority elders, unless they are culturally sensitive. Look at the box on page 555 (also on p. 552). The cultural barriers refer to issues related to ethnicity – language issues, or distrust of the government due to Tuskegee or the Japanese internment camps, for instance, or personal experience with prejudiced health care providers. “Lack of knowledge” of how to “do” medical appointments is not uncommon. Imagine you walked into a clinic in Peru or Tanzania or Denmark – would you know what to do? Do you sit and wait? Do you sign in? Do you answer the doctor’s questions, or launch into your own description? Do you know how to say “shortness of breath” in Spanish or Tanzanian or Danish? Think about how an emergency room visit works in the US – first you check in at the desk, then (sometime later) you see a person who takes your vital signs and writes up a brief assessment of whatever your issue is. Then (even later), you are maybe taken to a room (if they have one) and an actual doctor might see you and might order tests which might require going to another room and seeing yet another medical specialist of some kind. Etc. At any point in there, you might mistakenly think, OK, you’re done (especially if you’ve been sitting there waiting for three or four or five hours), and leave. And contrast this with the other ER scenario -- you are rushed immediately back to some room where your clothes are literally ripped from your body and various things (tourniquets, sensors, whatever) applied, and people are shouting and running and you are scared to death. It’s confusing enough for someone who speaks English and has “been there, done that” before. Imagine what it is like for someone whose English is limited and has no clue what is going on. Economic barriers refer to “real” barriers tied to a lack of income (such as a lack of transportation, or no health insurance) and also psychological barriers related to having a low income (the stigma associated with going to a government clinic, which implies that you are “poor” and receiving “government charity”). Structural barriers are characteristics of the system that make it difficult for someone to access or use health care. These may or may not be directly related to ethnic minority status (e.g., lack of transportation is due more to income than culture, although ethnic minorities tend to have lower incomes than the white majority). But – medical clinics that are operated by an all-white staff may be off-putting to a Hispanic or black or Native American clientele, who may refuse to go. Staff who speak only English may not be effective serving in an Indian (meaning India) or Korean neighborhood, and failure to respect cultural differences can alienate patients. Clinics located in an upper-middle-class suburb (not that any are!) are out-of-reach of the clients they are trying to serve. Look at the bulleted list on page 556 (“service use by elders of color is increased by the following conditions”): 1) Put the clinics IN the neighborhoods. Provide transportation. (You can enlist local churches and community agencies to help with that.) A medical van that regularly visits the neighborhood can provide ongoing care to small populations. 2) Learn about the predominant cultures you will be serving. What do they eat or not eat? What kinds of recreation are popular among older adults in their culture? What kinds of music do they enjoy? What other social customs do they follow (e.g., eye contact, touch, gestures, ...)? What are their holidays and how do they celebrate them? Etc. (The food one is a good example – if you are treating Orthodox Jews, don’t serve pork and do respect kosher laws; if you are treating Hindus from India, don’t serve beef; if you are treating Asian Americans, include rice and vegetables and fish in their meals; etc.) 3) Everything should be available in their native language. Even if they speak English fairly well, they may not know the medical terms. 4) Include members of their community in the planning for the clinic as well as ongoing issues. (Create an advisory board that is predominantly members of that ethnic group.) 5) Use whatever outreach works best for that group – churches / mosques / etc., radio stations, TV programs / channels, community events, etc. 6) Know what health issues are most likely among that ethnic group and ways to screen for them that are respectful. Know ethnic differences in how those health issues might manifest themselves. Discussion Question #4: Do you have any examples of barriers that made it difficult for someone to access service? Or of “enhancements” that increased outreach to a minority community or made the service more receptive to them? Chapter 15: Older Women We have already looked at lot of this information in other chapters, so I will be focusing on only a few points. We are also looking at custodial grandparents in this chapter. Pp. 564-566 -- General Info As noted before, most older adults are women, so it is important to consider the different needs and issues that affect older women. These include the higher levels of poverty, relative to men; the increased likelihood of living alone (due to a longer lifespan, plus generally marrying a man who is several years older, plus not remarrying after widowhood or divorce); the increased likelihood of living in a care facility (due to the lack of a care-providing spouse); and the higher likelihood of being a caregiver, whether for their own husband / partner or their parents or in-laws. Notice how very recently women’s issues began to be studied in terms of aging.

Pp. 566-571 – Economic Status Note the difference in median income – older men have almost twice as much income as older women. Note the line “lower lifetime earnings produce lower retirement and higher poverty.” This is so true. For instance: My husband and I decided when we had kids that I would mostly stay home (a common decision among many couples). So, he continued to work, and at a full salary, with benefits. I worked part-time (sometimes VERY part-time), with a low salary and NO benefits. I don’t have any “zero years,” as I have always worked at least some, but I have many years where my income was less than $10,000. Social Security benefits are based on average salary over 35 years. The person who works continuously for 35 years, making an average of say $50,000, is going to have a lot more in Social Security benefits than the person who worked only 27 of those 35 years, at an average salary of say $18,000. And don’t forget eligibility for retirement benefits – my husband has been eligible since Day 1, when he was 29 years old. I did not become eligible until I was 42. (Because I was an “adjunct faculty” member, with NO benefits of any kind – retirement, medical, etc. – before I became a half-time lecturer, which means I was now eligible for benefits. I am now a full-time lecturer, with benefits.) So, when he is 65, he will have 36 years’ worth of retirement benefits to draw from, while I will have only 23. This decision of ours to have me work part-time is going to seriously adversely affect me in retirement, especially if he dies. (Actually, we both have more years, since he worked at Texas Instruments before getting his PhD, and I worked there, too, for two years before we got married. I also worked at Wright-Patterson AFB for one year after we were married, so I will actually have 26 years of full-time employment, plus a number of years of reduced contributions due to working part-time. He also contributed to SS when he was a graduate student, making his whopping $10,000 a year as a graduate assistant.) See the “spousal consent requirement” on p. 570. I think the book is confusing here, so I will explain it. A woman who has been a “housewife,” and later is widowed, may benefit from her husband’s pension only if 1) he does not die before retirement age and 2) he is willing to reduce his monthly benefits in order to provide her with a survivor’s monthly annuity. (Skip over the “stays married to her” part, which gets tricky.) OK, these mean that if he dies before he retires, the pension may not kick in until the age of retirement (normally 65, but it can vary). She would presumably get a life insurance payment, if he has a life insurance policy, but the pension may be delayed or even, potentially, gone (depending on the company he works for, etc.). And, if he’s already retired, once he dies his benefits stop – unless he’s signed the “husband and wife pension agreement” that reduces his monthly benefits. Here’s how it works: The reduced benefit is the original benefit multiplied by (91% minus 0.4% for every year his wife is younger). So ... let’s say the original benefit is $3,000 a month (which is $36,000 a year). Let’s say Mr. Jones is 65 and his wife is 60. Their age difference is five years. Five times 0.4 is 2.0. So we shall multiply the $3,000 by (91% minus 2%), which means $3,000 times 89%, which is $2,670. Thus, instead of receiving $3,000 a month, Mr. Jones and his wife will receive $2,670. If Mr. Jones dies, his wife will then receive half of that ($1,835) each month until she dies. Bear in mind that the average pension is less than $5,000 a year ($416 a month), which means you are almost down to pennies for the widow. (Assuming the same 5-year age difference, 89% of $416 is $370 a month, which divided by two is $185 a month for our widow. Wow! That oughta keep her well-fed and warm in the winter! But – she will be poor enough to be eligible for SSI! Woo-hoo! How comforting.) In most states, the husband MUST sign the “husband and wife pension agreement,” or have his wife sign a spousal consent form to waive the agreement. However, not all states require this, so many women are left high and dry following the deaths of their husbands, with NO income coming in (except possibly some Social Security). This is both a middle-class effect and a cohort effect, as most middle-class younger women have been employed and will have access to their own Social Security benefits, as well as pensions (if applicable). But many middle-class women over age 55 have never worked for pay and are truly completely dependent on their husbands for financial security, even after the husband dies. Many low-income women, even younger ones, do not have pension benefits and do not pay into Social Security. Low-income women will continue to have extreme financial stress unless some serious legislative reform occurs, which is doubtful. Bear in mind that this is the “SPOUSAL pension agreement.” Non-married partners (whether heterosexual or homosexual) have NO access to post-death benefits from a partner’s pension. Once the partner dies, the money is gone. Kaput. The fact the couple has been together for 50 years is irrelevant. (I will note, though, that heterosexual couples can choose to marry or not marry.) Note also another limitation of the Family and Medical Leave Act – not only are you not paid while you care for a family member, but you also are no longer earning credits toward Social Security or a pension. (Pardon me while I pull my hair out.) Pp. 572-578 – Health Most older women do not have health insurance except through their husbands’ policies. This includes Medicare, which only applies to people who have paid into Social Security, and their dependents. (And, to get slightly side-tracked, just think what it must be like to be a grown adult who must continually be referred to as a “dependent.” Is that not somewhat infantilizing?) So, let’s imagine a widowed woman, age 69, with no health insurance of her own (because she was a homemaker for forty-eight years), no health insurance through her husband (because it stopped when he died, assuming he had any to begin with), and no access to Medicare because he did not pay into Social Security due to the nature of his job. This does leave one in a bit of a pickle, does it not? If her income is low enough, she may qualify for Medicaid, which is hardly reassuring. As the book notes, most people who depend on Medicaid are in fact women (whether single older women or single mothers of young children), and so increases in Medicaid deductibles and reductions in coverage primarily target women. Note the “pickle” the divorced woman in her 50s with cancer faces (middle of first column, p. 573). Too young for Medicare, too sick to buy private insurance (cancer being one of those pre-existing conditions that cause insurers to turn you down), too “rich” for Medicaid, and no husband’s insurance coverage now that she’s divorced. Notice that 85% of older women have at least one chronic disease or disability. Notice also that older men are more likely to experience life-threatening conditions that require hospitalization. Bear in mind that Medicare covers hospital care at 80% but pays little toward treatment of chronic conditions (e.g., prescription drugs, regular doctor visits). So, men are more likely to reap more benefits from Medicare coverage, just because of the way Medicare was originally set up. (To cover acute illnesses and hospitalization.) Notice that (page 574) cardiovascular disease kills more women than the next 16 causes of death combined. AVOID CARDIOVASCULAR DISEASE!!! Notice the two primary causes – unhealthy diets, lack of exercise. Notice also that women over age 60 or so seem to have this idea that “reproductive diseases” (ovarian cancer, uterine cancer) are no longer a worry for them (because they are post-menopausal), and so they don’t get Pap smears or have mammograms done. Tsk, tsk. These are actually MORE likely in older women. Notice that beginning an exercise program even in the 70s and 80s still has positive effects on fitness and strength. Isn’t that first paragraph on osteoporosis scary?!? No warning signs, even simple coughing can cause a fracture, the dowager’s hump, and then the paralysis that fear of falling causes so many women to have no life whatsoever. Note the ways you can prevent these things on page 576 (box)! Skip menopause because we’ve already covered it enough. Pp. 578-581 – Older Women’s Social Status Look at that statistic about length of widowhood – at the turn of the (19th) century, widows lived alone for 5-10 years, versus 24 today. That is a HUGE difference. I wonder – it can’t be because their husbands today are dying at younger ages (because obviously men live longer now than they did in 1900), so it’s either that women are living longer (true) and / or, more likely, that they used to move in with an adult child at a younger age and now that is delayed if it happens at all. Of course, that probably means that their health is overall better, for a longer period of time, so that is a good thing. (In the “old days” a widow or widower often immediately moved in with family members, even if their health was excellent, simply because they could not survive on their own due to not knowing how to do the other sex’s household chores.) Look at what living alone can be linked to – malnourishment, increased susceptibility to infection, and of course a more limited social life. Bear in mind that these are just possibilities. My grandmother lived alone from 1960-1996, and she was healthy, well-nourished, and had a very active social life. Notice that black and Hispanic older women are more than twice as likely to live with family members than older white women are. (And recall that almost two-thirds of Native American older women live with family members.) That is all we are going to cover, as most of the rest has been hit on before. Discussion Question #5: Any comments about older women you know and the husband-and-wife pension agreement? (Do women you know who are in their 50s and 60s even know about that?) How about older women and health insurance? Or anything else in this section. Pp. 325-329 – “Custodial” Grandparents (from Chapter 9) This is a HUGELY growing phenomenon. Estimates are that about 2-3% of all children (in the US) live with grandparents and no parents (the skipped-generation household). That is a LOW estimate. You may have noted that I put “custodial” in quotation marks in the header. That is because many grandparents do have legal custody of grandchildren, but many, many more (no exact numbers are available) have physical custody, with no actual legal rights. (Legal custody involves the court system, and can be temporary. It is awarded by the courts and can be taken away by the courts. There is no guarantee that a child will stay in the grandparents’ home. It is quite possible a judge will decide that a grandparent cannot care for a grandchild as needed, or that a foster home would be a better place – so, rather than risk losing the grandchild entirely, many grandparents forgo pursuing legal custody, and live in a “legal limbo.” They also don’t report that the grandchild lives with them, which is why the 2-3% is low and why no exact numbers are available.) Your book notes the 2003 Supreme Court ruling regarding foster care benefits. Prior to this ruling, grandparents who were not formal foster parents, but who had legal custody of their grandchildren, could not receive the normal benefits provided to foster parents (medical insurance, stipends to cover expenses, etc.). Now, grandparents are (or can be) eligible. However, as the book notes and I did above, the majority of custodial grandparents have NOT sought the legal custody necessary to receive those benefits, for fear the child could later be taken away. Grandparents do not generally raise their grandchildren unless there are some pretty serious issues involved – parents who have abandoned the child, parents in prison, parents strung out on drugs, parents who have died. So the grandparents are not only dealing with their own aging issues AND child-rearing, which can be difficult enough, but also with the psychological baggage, in the child, that goes along with having a parent die, or leave you, or be in jail. (The “past traumatic circumstances” noted on p. 327.) Notice, also, the losses the grandparents experience (income, social life, etc.), as well as psychological issues such as guilt if they felt they contributed to the situation (e.g., did not raise their own child “right,” resulting in their own child becoming addicted to drugs). Discussion Question #6: Any examples of custodial grandparent issues? Also, if you have comments on the Tuskegee Study (see other file, or link), please add them.

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Comments for Week 15, Social Policies (Chapter 16) – Perspectives on Aging Pp. 590-591 – Background Notice that our aging policies were all established within the past 70 years or so – in other words, about the time that the current older adults were just being born or were still children. When you think of what the world was like THEN, especially in terms of aging, and what it is like NOW -- you get a great example of the importance of cohort differences! Notice the huge change in percentage of the federal budget (13% in 1960 vs. 45% in 2001, and expected to rise to 70% by 2030). Of course, percentages don’t necessarily mean a whole lot, because if the overall “pie” is bigger or smaller, the funding could stay the same but equal a much larger or smaller percentage. However, I think we all know that the federal budget hasn’t exactly shrunk in the past 40 years! Your book also notes that the bulk of “gray” spending (92%) is for Social Security and Medicare. That is phenomenal. This is also why so much debate, etc. is devoted to those two areas of the budget. (“Gray” spending means money spent on older adults’ issues.) Finally, the book says, “The United States lacks an integrated, comprehensive, and effective public policy to enhance the well-being of all older adults.” Key words there are “integrated,” “comprehensive,” “effective,” and “all.” Remember that Medicare and Social Security are only for people who have paid into the system during the work years. (And it wasn’t like it was a choice – either your job included SS benefits, or it didn’t. The individual couldn’t “opt out” OR “opt in.”) So, one problem is figuring out a way to cover ALL older adults, regardless of their work history or lack thereof. (What about all of those housewives? what about day laborers, migrant workers, smallbusiness owners who did not pay into Social Security back then?) As we saw before, Medicare is also not particularly “integrated.” If it were, you wouldn’t have to fill out this form for this procedure and go to that place for that procedure and so on. You would just go to one place and do whatever needed to be done. And as far as “comprehensive” goes, there wouldn’t be exclusions for dental or visual care, or only certain doctors, and so on. Your HEALTH care (meaning all of your health) would be covered (although perhaps not at 100%). And “effective” means it would reach every older adult who needed it, regardless of language spoken, poverty level, location, etc. It also means it won’t break the bank in terms of cost. If you have any ideas for how to do this, please contact Congress! (You could file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (1 of 13)5/4/2007 4:39:57 AM

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do all of it quite well, actually, if you had an unlimited budget. It’s that little fiscal issue that causes all the problems.) Discussion Question #1: If any of you knows details of how other countries handle health care coverage for older adults, please share. Pp. 592-593 – Program Types Notice that policy is a rather complex concept. A policy includes a goal, and a general philosophy to reach that goal (or goals). The specific steps taken are the programs. So, if the goals are to reduce poverty and increase health among older adults, the general philosophy may include such things as “aging in place” (meaning you don’t move people, but you bring services to them), providing preventive health care, enhancing quality of life, and providing some kind of income. The specifics of how these are done are what make up the programs. So a program might be “Meals on Wheels” (which allows aging in place) or the “Mammogram Van” (which screens for breast cancer – prevention – and also brings the procedure to the people who need it). The table on page 593 lists some of the specific programs, the populations they serve, and the forms of some of the benefits. Notice that Medicare is an ageentitlement program, but Medicaid is need-based. If a program is based on age alone, then anyone who meets that criterion (the age) may take part. This has been a problem for Medicare lately. Some people argue that Medicare should have a ceiling so that higher-income older adults (let’s say a Rockefeller or a Kennedy), who do not need the Medicare benefit either do not receive it or must pay higher premiums, thus freeing up more Medicare money for lower- and middle-income older adults, who do depend on Medicare for their health coverage. However, that would be going against the philosophy of Medicare, which is that ALL adults age 65 or older (who are eligible for Social Security) receive coverage, and it would change it from an “entitlement” program to a “need-based” program. (See pp. 612-613, Neugarten’s argument.) Note, too, that the current cohort of older adults is very wary of anything appearing to be “charity” (because of their experiences in the Great Depression), so changing Medicare to a “need-based” program would, in their eyes, be changing it to charity. No way are they going to let that happen. They are much more comfortable feeling “entitled.” (Aren’t we all?) Benefits can be direct or indirect. Direct means they are paid directly to you, for instance as a Social Security check. Indirect means you get the benefit in a more convoluted way, often as a reduction in your income taxes. If you can write off your prescription drugs, eventually you will get back part of what you paid for them (assuming file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (2 of 13)5/4/2007 4:39:57 AM

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you itemize on your tax return), but you will first have to pay up-front, and do notice that you don’t get all of the expense back – it just reduces your income so your taxes are lower. (Example – say your income is $50,000 and you are taxed at a rate of 25%. That means you would pay $12,500 in taxes. Say you spend $5,000 on prescription drugs, which you can write off. Now your income is reduced to $45,000 and you pay only $11,250 in taxes, thus saving $1,250.) Notice that there are also direct and indirect benefits that are paid in non-cash forms (called “cash substitutes”). Foodstamps are a direct, non-cash benefit. They come directly to you, they are not cash, and they have certain restrictions on what they can be used to purchase (namely, food – but why Twinkies are allowed and toilet paper isn’t seems a bit ridiculous). Medicare (and most HMOs) pay indirect non-cash benefits – you go to the doctor and pay the co-pay, but the bill is sent to Medicare or the HMO and the doctor is paid by them. You never see an actual cash benefit. (With other HMOs and most PPOs, you pay everything up-front, send the receipts to the HMO, and they send you a check – that would be a direct cash benefit.) The other two categories refer to contributory / noncontributory programs, and universal vs. selective benefits. For contributory programs, you are entitled to benefits only if you paid into the program (a pension fund, for instance, including Social Security). Noncontributory programs are generally need-based; as long as you are poor enough, or meet other criteria, you may receive benefits from that program. Medicare is contributory; Medicaid is noncontributory. Universal just means everyone in a certain category, regardless of need, income, eye color, whatever, is eligible for benefits, and selective means only certain people are eligible. Medicare is considered a universal benefit, although it really is not, because if you (or your spouse – and it has to be a legal spouse, not a partner) didn’t pay into Social Security you aren’t eligible for Medicare. However, 96% of older adults are eligible for Medicare, so it is “almost” universal. It also means, to tie it back into the point made three paragraphs up, that even if you are a Rockefeller or a Kennedy, you are entitled to Medicare benefits. So, as long as you paid into Social Security and are at least 65 years old, regardless of anything else, you are eligible for Medicare. It is a “universal contributory” program, open to all people who contributed, as long as they are 65 or older. Isn’t this a MESS?!?! You can see why trying to tidy up the Medicare package is not an easy task! Let’s look at this in terms of adding prescription drug coverage to Medicare (Plan D). (Recall that that was not included back in 1965 because no one really thought about it, as prescription drugs were a very back-burner issue.) Part of the debate was on whether prescription drug coverage should be “universal” or “selective.” One suggestion was to make co-pays income-dependent (so that those with higher file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (3 of 13)5/4/2007 4:39:57 AM

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incomes pay higher co-pays), however, that would change that part of the Medicare benefit from universal to selective, and of course people are worried that a domino effect will follow, with other limitations on coverage for those with “high” incomes – “high” being relative and subject to lowering. So, while most people can probably agree that it is no big deal to make multi-millionaires pay for their prescription drugs, what about people making $200,000 a year? $100,000? $50,000? What if my income is only $30,000, but I have assets worth two million? There were other issues – cover only generic drugs (kind of selective-sounding), raise premiums for people with higher incomes (selective, too), and so on. Very complicated. Plan D is, in my opinion, rather inadequate and not likely to have much impact on a large percentage of older adults. But this chapter is complicated enough without going into all of that. (Another great career field, though, for those of you interested in public policy. Someone is going to have to explain these kinds of programs to people – individuals, corporations – and lots of someones are going to have to work on the details of how the money balances out.) Discussion Question #2: Ask older adults who receive Medicare what they think a reasonable solution would be. Do they think it’s OK to have a sliding scale for prescription drug coverage? What about other health care? Should there be an income ceiling? If there were one, what should it be? Pp. 594-596 – Development of Public Policies It is very difficult to plan for public policy for a number of reasons, two of which are noted in the book. One is that whatever plans are made today may or may not be relevant twenty or thirty or however many years in the future. Thus, the original Social Security act has had to be modified as it didn’t quite meet the needs of the recipients (not to mention it excluded numerous categories of workers), and it continues to be a problem as life expectancy greatly exceeds the expectations from back in 1935. In addition, the “shortsightedness” issue means people (legislators) tend to focus on what will fix the problems we have today, without worrying about the problems we may have tomorrow. (Part of this, in my humble opinion, is that they are worrying about getting reelected. Same thing with corporate officers who worry about next quarter’s bottom line and not long-term growth.) So, depending on which political party is in power and other issues going on (e.g., having to spend lots of money on, say, defense or homeland security or hurricane relief), different values and priorities may prevail, at the expense of long-term issues. The book notes that Americans are generally conflicted over how much file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (4 of 13)5/4/2007 4:39:57 AM

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responsibility should rest on the shoulders of the individual versus how much society has a responsibility to care for its less-able members (“less-able” meaning older adults, children, people who are disabled, etc. – people who cannot hold jobs, in other words). We see this conflict in welfare payments to single parents, school funding issues, and medical insurance, in addition to aging-related programs. So, some people will argue that it’s too bad you made poor choices earlier in your life, but why should my hardearned tax dollars go to support you?, and others will say that as a society the morefortunate are responsible for the general welfare of the less-fortunate. (And after all, who “chooses” to be born into poverty and go to sub-standard schools, and is it really a “choice” to drop out of high school and get a job so your family can eat, versus staying in school and starving to death? People who criticize others for their “poor choices” tend to have never faced such stark circumstances. Which is not to say that some people don’t make poor choices, because clearly they do. But a poor choice made 50 years ago should not really be relevant to the fact that right now they don’t have enough income to pay for both their heat and their prescription drugs.) Social Security has been met favorably by people who believe in individual responsibility for two reasons: 1) it benefits those who have paid in (“contributed”), so they are seen as “deserving,” and 2) it benefits the middle class. Note what the book says: “The Great Depression dislodged the middle class from financial security and from their belief that older adults who needed financial assistance were undeserving.” When it was the poor being dislodged from financial security, the middle (and upper) class could shrug their shoulders, but when it happened to THEM ...! All of a sudden they were “deserving.” (In general, issues that don’t affect the white middle-class get short shrift; once those issues do affect the white middle-class, headlines suddenly scream. This happened with nursing home care in the 1930s, with juvenile delinquency in the 1960s, with out-of-wedlock pregnancies in the 1980s, and now with Medicare coverage in the 2000s. All of those issues affected non-white, non-middle-class groups for decades before they became “Issues.” See below.) The book also points out (going back a couple of paragraphs) that “older adults are often viewed as a powerful, organized constituency. As a result, they are more likely than low-income or homeless families ... to arouse a favorable response from politicians.” One of the reasons older adults are able to be powerful and organized is because so many are middle-class. They have the time and the means TO organize, unlike low-income or homeless people, who are concerned with survival. Of course, middle-class people are also more likely to vote, and so politicians are going to pay more attention to them than to blocs with low voter-turnout histories. On p. 596, first column, it says “priority is placed on the most efficient and the file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (5 of 13)5/4/2007 4:39:57 AM

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least expensive solutions, rather than equity and the common good.” Unfortunately, “you get what you pay for,” and so doing things on the cheap (whatever is “least expensive” NOW) often results in bigger consequences later. Pp. 596-597 – Initial Policies Notice that prior to the 1930s, the US federal government had basically no social programs for older adults. Families and local communities were expected to cope with whatever problems and issues arose. Needless to say, in many cases neither the families nor the communities had the resources to cope, in particular if the families or communities were poor. However, since that didn’t affect middle-class America, it could be swept under the rug. Then, the Great Depression came along, and suddenly a LOT of people (formerly middle class) were poor, and a LOT of families and communities couldn’t cope with their needy older adults, and in addition there was a shortage of jobs for younger adults (mostly men), and so this set the stage for the development of Social Security – a way to encourage older adults to retire so that younger adults could have work, and to guarantee an income so the older adults could buy food and heat their homes and not be so dependent on their families or communities, who were stretched so thin. Initially, Social Security excluded agricultural workers (many of whom were black, and most of whom were poor), people who worked for schools, churches, or charitable organizations (most of whom were women), and those who were selfemployed (who tended to be upper-income – lawyers, doctors, business owners – or lower-income – domestics, handymen, day-laborers). So, as you can see, it was basically set up to benefit the people whose lives had been most changed by the Great Depression – the middle-class, white, professionals, nearly all of whom were male. (If you were dirt-poor prior to the Great Depression, you were still dirt-poor during it, so there wasn’t much change. If you were Very Rich before, in most cases you continued to be Very Rich, because you had enough assets to tide you through. Of course, some very rich people did lose just about everything, but mostly it was the middle class who was affected by the Depression.) Recommended book: The Worst Hard Time: The Untold Story of Those Who Survived the Great American Dustbowl by Timothy Egan. Review here, at Amazon. com: http://www.amazon.com/Worst-Hard-Time-Survived-American/dp/0618773479/ ref=pd_bbs_sr_1/102-7577948-3114545?ie=UTF8&s=books&qid=1176145837&sr=1-1 In the 1950s, Social Security was expanded to include agricultural workers, selfemployed people, and also spouses. file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (6 of 13)5/4/2007 4:39:57 AM

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Discussion Question #3: Ask older members of your family how their (or their parents’) lives were impacted by the Great Depression. Would they have been eligible for Social Security as it was first implemented in 1935? How did any of the New Deal programs help them or their family? Pp. 597-599 -- 1960s-1970s As part of the “Great Society” program, Medicare and Medicaid were introduced in 1965. Look at what the book says, because this is the root of some of the problems we have now: “[it was] assumed that most older adults are deserving poor, frail, illhoused, unable to keep up with inflation, and therefore in need of government assistance.” In the 1960s, that was true. Most older adults WERE poor, frail, ill-housed, etc. Social Security provided a bare-minimum income for most people. There was no health insurance, and medical care and personal diet / exercise choices were generally mediocre. So, older adults tended to be lower-income, often in poor or not-so-good health, living in housing that was not a good “fit” for their needs (e.g., drafty, needing repairs, with bathrooms on the second floor, etc.), and generally just eking it out. America as a country, however, was still in the midst of the incredible post-World War II economic boom. It made sense to be generous to the less fortunate, to extend a hand to those poor, frail, older adults who had done so much to make America a great country. Part of the solution to that, to avoid the stigma associated with government “handouts” (especially bothersome to this Depression generation), was to make much of the assistance age-based, not need-based. Bear in mind that at that time life expectancy was still only around 70 (for those born in 1965), so it was not believed that people would use Medicare / Medicaid for too many years before they died. Now, fast-forward to today, when a huge number of older adults (at least those in their 60s and 70s) are actually in quite good health, have middle-class incomes, receive Social Security benefits that are indexed to inflation, and actually do NOT need much government assistance. (They also can expect to live to their 80s and 90s and 100s.) You can see where the view of older adults as a group in 1965 is not quite congruent with the reality of older adults in 2007! Which has led to the debate about changing Medicare, etc. to “means-tested” programs, or charging higher premiums based on income, or delaying eligibility, or many other things.

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Another root of some of the problems today lies in a sentence on the next page in your text – “programs that obscured individual and subgroup differences among the older population.” Basically, Medicare, like Social Security, was built around a middleclass, white, male model, which does not describe the majority of older adults. In the 1960s, even though the Civil Rights movement had made considerable progress and was on the front pages of newspapers on a daily basis, most “people in charge” (upperincome, well-educated, white men) were still pretty oblivious to the realities of differing needs and experiences based on race and ethnicity (the distrust of government-run medical facilities, the lack of transportation, the isolation in rural areas, the lack of basic services like running water, the lack of English, and so on). So, with the best of intentions they created a program that certainly was an improvement over what came before, but that didn’t address the complexity of the needs, and today we are wrestling with how to modify this great big lumbering elephant into something that will work, and still be fair, and reach the people who most need it. In the 1970s, more modifications to Social Security were made – benefits were increased and a “cost of living adjustment” (COLA) was added, so that benefits would rise each year, based on inflation. This was not a moment too soon, too, as the oil crisis was just hitting and inflation would soon skyrocket. (I remember in 1973 or 1974 gas cost 50 cents a gallon, except there was one place on the Pennsylvania Turnpike – we were going to Niagara Falls – where it was 75 cents a gallon and my dad gave the owner a talking-to about price-gouging. [I’m sure the owner laughed all the way to the bank.] A year later we would have cheerfully paid 75 cents a gallon, as it had risen to 80 or 90 cents by then.) Pp. 599-600 – 1980s and 1990s OK, after expanding Social Security and other assistance to older adults in the 1960s and 1970s, the 1980s and 1990s saw a contraction of benefits, including taxing Social Security payments at certain income levels. The World War II cohort was beginning to enter older age now, and they were a very different group compared to the previous cohort. For one thing, they had benefited tremendously from the economic boom of the 1950s and 1960s, not to mention the GI Bill, and also the impact of inflation on house prices, which allowed them to make a tidy killing when they sold their house. In the meantime, child poverty rates were going up, and so people began looking at the federal budget and saying “Huh! Why are we giving these comfortably-set older folks all this money, when little children are going hungry?” Why, indeed. And the answer of course is because Social Security and Medicare are AGE-based programs, not means-based. file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (8 of 13)5/4/2007 4:39:57 AM

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As your book says, “During the 1980s, the political reality of the economic and social diversity of the aging population – that chronological age is not an accurate marker of economic status or functional ability – became more apparent.” (Emphases added.) In the 1960s, older adults were seen as a homogenous group, and chronological age actually was a pretty good marker of economic status (that is, most older people were lower-income). But all of that had changed by the 1980s. Which led to a realization of the three groups described in your text: The first, which desperately needs governmental assistance but isn’t eligible for it; the second, which needs governmental assistance and gets it; and the last, which does not need governmental assistance, but gets it anyway. What to do, what to do? What they did was they reduced benefits to the last group, which made more money available to the middle group, but which didn’t exactly help the first group. Also the last group kicked and screamed about being discriminated against. Sigh. As your book notes, there has been a transition from “old-age-deserves-benefits” to “age-alone-is-not-sufficient.” P. 600 – The 1990s The federal deficit got bigger, and it was apparent that, just as with losing weight you need to EAT LESS and EXERCISE MORE, the federal budget was going to have to either RAISE TAXES or CUT SPENDING. Social Security was not touched, but Medicare and Medicaid were, and that is all you need to know about this section. Pp. 601- 604 – Income Security Note that Social Security does not just fund retirement income – it also funds disability insurance (so if you, at age 25, are disabled and cannot work, you will still get SS benefits). Originally only 60% of the labor force was eligible to receive Social Security (that was due to the exclusion of the groups mentioned above, such as agricultural workers). Now, it is close to 96%. That is a good thing, BUT – keep in mind that Social Security is “not an investment program or the sole source of retirement income, but rather a minimum floor of protection.” (Which kind of makes you wonder what SSI is, since it pays even less than Social Security. A sub-minimum floor of protection?) However, file:///F|/Documents%20and%20Settings/Justin/My%20...204/Comments%20on%20Chapter%2016%20(Week%2015).htm (9 of 13)5/4/2007 4:39:57 AM

Comments for Week 15, Social Policies (Chapter 16)

Social Security is the ONLY source of income for almost 20% of retirees, who have no employer-sponsored or private pensions. (Here’s the 2004 data on that: the poorest 20% of retired people get 82% of their “income” from Social Security, 8.4% from public assistance – foodstamps, etc., 3.5% from pensions, and the rest from asset income, earnings, and “other.” The poorest 20% makes AT MOST $10,400, which means many make much less – only $8,000, say, or $5,000. So, if you do the math, they are getting, at most, $710 a month in Social Security, $72 in public assistance, and $30 [THIRTY!] in pension income. If they make $8,000 a year, they get $547 a month in SS, $56 in public assistance, and a whopping $23.33 in pension income.) Notice that Social Security is financed by its own payroll tax, NOT “income tax.” The next time you get paid, look at your pay stub. The FICA/OASDI withholding is the money you give to Social Security. You should also have withholdings for Medicare and for the federal government. That FICA money goes directly to Social Security. Retirees are paid directly from that fund and the EXCESS (there is a LOT of excess) is then “borrowed” by Congress to fund other Federal programs, and this is a main reason why some people think there is a crisis in Social Security. What there really is is a crisis in Congressional spending – it spends money it doesn’t really own. Social Security has three kinds of funds: the income that it takes in and immediately pays out in retirement benefits; the excess income that is not immediately needed, known as the Reserve or Trust Fund (most of which is borrowed, and spent, and NOT paid back, by Congress), and the interest on the Reserve. Imagine Social Security has $100 total income, and must pay out $60 to current retirees. The other $40 is then borrowed (and spent) by Congress, which pays only the interest back into Social Security (let’s say it’s $5, which is an exorbitantly high 12.5% interest rate, which trust me Congress is not paying!). Thus far, Congress has failed to pay back the funds it has borrowed for year after year after year after year, ad nauseum – which are MORE than enough to fund Social Security basically forever. So, Social Security SHOULD have this year’s $40 excess, plus last year’s excess, plus the year before that’s excess, etc., back to the 1940s, which is a LOT (a lot!) of money. Except instead it only has those measly little $5 (or less) interest payments from all of those years, which is Not Enough. Everyone worries about the Baby Boom retiring and the drain on Social Security, but they forget that the Baby Boomers will quit drawing on Social Security around the year 2065 (when the youngest Boomers will be age 101), and the next generation (Generation X) is much smaller than the Baby Boom, and so will need to draw out much less in Social Security retirement pay.

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Comments for Week 15, Social Policies (Chapter 16)

Notice that today’s retirees “generally recoup their SS contributions within seven years.” When Social Security was set up, most retirees would not have lived long enough, after retirement, to recoup anywhere near seven years’ worth of contributions. Now, a large number will continue to draw Social Security payments for twenty or thirty years after retirement. That means they are drawing out way more money than they contributed. But recall that Social Security is paid for by current workers. It is not “a funded pension system in which retirees are merely paid back, with interest, the ‘contributions’ they made during their working years.” If it were, then after that seven years or so Social Security payments would abruptly stop. (One possible reform of Social Security would be to give retiring workers a lump sum of all the money they contributed, plus interest. They could then invest as they wished, but they would get no monthly income and no more money past that lump sum. It does seem a bit unfair if someone contributed the equivalent of $250,000 over their life time – counting interest – that they might collect two or three or four times that, due to living so long. Invested decently, that $250,000 could last a very long time.) Notice that payroll taxes to fund Social Security have crept ever upward – from 1.5% (employee portion) in the 1950s to 6.2%. Medicare is an additional 1.45%. (Employers also contribute, paying the same amount as the employee.) Pp. 604-608 – Options The book says (p. 605, first column) “Most proposals for change suggest that the only way to [fund Social Security] in the future ... is for the federal government to raise payroll taxes, increase the age of eligibility, use means testing, increase borrowing, reduce benefits, or rely on economic growth.” Let us just look at those for a minute. 1) You could raise payroll taxes. You could limit the rise in payroll taxes to only the top x-percent of tax payers, or to people making at least y-amount of money. You could also extend the ceiling for paying into Social Security. Remember that right now you only pay SS deductions for the first $90,000 or so. You could require people to pay in to Social Security for incomes up to $100,000 or $150,000, or $500,000. However, you would then have to pay more to those people when they start drawing on Social Security, so that might not work, mathematically-speaking. Also, people tend to be Not Too Happy about their taxes being raised, especially if they don’t see any benefit accruing to themselves. Right now, the younger Baby Boomers and Generation X (the one after the Baby Boomers) are quite cynical about receiving any SS money, and if you file:///F|/Documents%20and%20Settings/Justin/My%2...04/Comments%20on%20Chapter%2016%20(Week%2015).htm (11 of 13)5/4/2007 4:39:57 AM

Comments for Week 15, Social Policies (Chapter 16)

raise their SS withholdings, they will be MAD. So, it would have to come with guarantees. 2) You could increase the age of eligibility to receive benefits. But that forces the workers who are least able to work to continue working (e.g., people whose jobs require hard physical labor). You could raise the age of eligibility for white-collar jobs but not for blue-collar jobs, but I don’t really see how that could be completely defined, plus some white-collar jobs are terribly stressful and some blue-collar jobs are not the least bit demanding (sitting in a toll booth), so that isn’t really fair. 3) You could do means testing. Well, that’s the one I like. The main argument used by people opposed to means testing is “we paid in just like ‘those people,’ and we’re entitled, blah-blah-blah.” But remember that Social Security is NOT a “funded retirement system” where you are paid back what you contributed. You are being supported by current workers. So I am not opposed to a reduction in benefits to people with high incomes. The problem is, what is “high”? Perhaps it could be a percent of the poverty line – as in anyone more than 1000% above the poverty line has SS benefits reduced by 20% or 50% or even 100%. (If poverty is $10,210 for a single person, which was the amount in January 2007, then a person at 1000% of the poverty line would be making $102,100 a year – in combined pension and SS payments, or investments or whatever other income they have. A 20% reduction in SS benefits would be peanuts – at most a reduction of $423 a month, if they get the maximum SS benefit ($25,392 annually, as of January 2007), on an income of $8,508 a month. You would still have $8,085 a month, or $97,020 a year. Even if you eliminated the SS payout completely for this group -- a 100% reduction -- it would leave a monthly income of about $6,400.) Or maybe everyone could be funded until they’d recouped what they paid in and then people at a certain income level would have their SS payments cut off. (These are all using January 2007 numbers, calculated on April 9, 2007.) 4) Increase borrowing. Not a good idea! You’ve got to pay it back, with interest, and that is NOT a wise decision! 5) Reduced benefits. You could combine that with the means testing and reduce only for certain higher-income segments, who will squawk. 6) Rely on economic growth. Right. Kind of like the Enron folks. This is just too unpredictable, and also too fluctuating. (By the way, I highly recommend watching the movie The Smartest Guys in the Room or reading the book Conspiracy of Fools, both of which are about the Enron mess. With Conspiracy, it would help to have an MBA, but I managed to understand most of it.) file:///F|/Documents%20and%20Settings/Justin/My%2...04/Comments%20on%20Chapter%2016%20(Week%2015).htm (12 of 13)5/4/2007 4:39:57 AM

Comments for Week 15, Social Policies (Chapter 16)

Or you could do the lump-sum option I mentioned above, but I’m not sure there’s sufficient money in the system right now to do it. It would warrant study. Your book has some more points on pages 605-608. Discussion Question #4: What thoughts do you have on these solutions? What holes do you see with my comments? Any combinations that you like? Skip the rest of this chapter, other than the Neugarten comments on page 612.

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The Tuskegee Syphilis Experiment

The Tuskegee Syphilis Experiment

The U.S. government's 40-year experiment on black men with syphilis by Borgna Brunner "The United States government did something that was wrong—deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens... clearly racist." —President Clinton's apology for the Tuskegee Syphilis Experiment to the eight remaining survivors, May 16, 1997

For forty years between 1932 and 1972, the U.S. Public Health Service (PHS) conducted an experiment on 399 black men in the late stages of syphilis. These men, for the most part illiterate sharecroppers from one of the poorest counties in Alabama, were never told what disease they were suffering from or of its seriousness. Informed that they were being treated for “bad blood,” their doctors had no intention of curing them of syphilis at all. The data for the experiment was to be collected from autopsies of the men, and they were thus deliberately left to degenerate under the ravages of tertiary syphilis—which can include tumors, heart disease, paralysis, blindness, insanity, and death. “As I see it,” one of the doctors involved explained, “we have no further interest in these patients until they die.” Using Human Beings as Laboratory Animals

Taliaferro Clark

Taliaferro Clark, Head of the U.S. Public Health Service at the outset of the experiment.

The true nature of the experiment had to be kept from the subjects to ensure their cooperation. The sharecroppers' grossly disadvantaged lot in life made them easy to manipulate. Pleased at the prospect of free medical care—almost none of them had ever seen a doctor before—these unsophisticated and trusting men became the pawns in what James Jones, author of the excellent history on the subject, Bad Blood, identified as “the longest nontherapeutic experiment on human beings in medical history.” The study was meant to discover how syphilis affected blacks as opposed to whites—the theory being that whites experienced more neurological complications from syphilis, whereas blacks were more susceptible to cardiovascular damage. How this knowledge would have changed clinical treatment of syphilis is uncertain.

Although the PHS touted the study as one of great scientific merit, from the outset its actual benefits were hazy. It took almost forty years before someone involved in the study took a hard and honest look at the end results, reporting that “nothing learned will prevent, find, or cure a single case of infectious syphilis or bring us closer to our basic mission of controlling venereal disease in the United States.” When the experiment was brought to the attention of the media in 1972, news anchor Harry Reasoner described it as an experiment that “used human beings as laboratory animals in a long and inefficient study of how long it takes syphilis to kill someone.” file:///F|/Documents%20and%20Settings/Justin/My%20D...204/Tuskegee%20Web%20Page%20version%20(Wk%2014).htm (1 of 4)5/4/2007 4:39:58 AM

The Tuskegee Syphilis Experiment

A Heavy Price in the Name of Bad Science By the end of the experiment, 28 of the men had died directly of syphilis, 100 were dead of related complications, 40 of their wives had been infected, and 19 of their children had been born with congenital syphilis. How had these men been induced to endure a fatal disease in the name of science?

To ensure that the men would show up for a painful and potentially dangerous spinal tap, the PHS doctors misled them with a letter full of promotional hype: “Last Chance for Special Free Treatment.” The fact that autopsies would eventually be required was also concealed.

To persuade the community to support the experiment, one of the original doctors admitted it “was necessary to carry on this study under the guise of a demonstration and provide treatment.” At first, the men were prescribed the syphilis remedies of the day—bismuth, neoarsphenamine, and mercury— but in such small amounts that only 3 percent showed any improvement.

These token doses of medicine were good public relations and did not interfere with the true aims of the study. Eventually, all syphilis treatment was replaced with “pink medicine”— aspirin. To ensure that the men would show up for a painful and potentially dangerous spinal tap, the PHS doctors misled them with a letter full of promotional hype: “Last Chance for Special Free Treatment.” The fact that autopsies would eventually be required was also concealed. As a doctor explained, “If the colored population becomes aware that accepting free hospital care means a post-mortem, every darky will leave Macon County...” Even the Surgeon General of the United States participated in enticing the men to remain in the experiment, sending them certificates of appreciation after 25 years in the study. Following Doctors' Orders It takes little imagination to ascribe racist attitudes to the white government officials who ran the experiment, but what can one make of the numerous African Americans who collaborated with them? The experiment's name comes from the Tuskegee Institute, the black university founded by Booker T. Washington. Its affiliated hospital lent the PHS its medical facilities for the study, and other predominantly black institutions as well as local black doctors also participated. A black nurse, Eunice Rivers, was a central figure in the experiment for most of its forty years. The promise of recognition by a prestigious government agency may have obscured the troubling aspects of the study for some. A Tuskegee doctor, for example, praised “the educational advantages offered our interns and nurses as well as the added standing it will give the hospital.” Nurse Rivers explained her role as one of passive obedience: “we were taught that we never diagnosed, we file:///F|/Documents%20and%20Settings/Justin/My%20D...204/Tuskegee%20Web%20Page%20version%20(Wk%2014).htm (2 of 4)5/4/2007 4:39:58 AM

The Tuskegee Syphilis Experiment

never prescribed; we followed the doctor's instructions!” It is clear that the men in the experiment trusted her and that she sincerely cared about their well-being, but her unquestioning submission to authority eclipsed her moral judgment. Even after the experiment was exposed to public scrutiny, she genuinely felt nothing ethical had been amiss.

Veterans' Administration Hospital in Tuskegee, Alabama

One of the most chilling aspects of the experiment was how zealously the PHS kept these men from receiving treatment. When several nationwide campaigns to The Veterans' Administration Hospital in Tuskegee, Alabama. Some of the study's posteradicate venereal disease came to Macon County, the men mortem exams were conducted here. were prevented from participating. Even when penicillin— the first real cure for syphilis—was discovered in the 1940s, the Tuskegee men were deliberately denied the medication. During World War II, 250 of the men registered for the draft and were consequently ordered to get treatment for syphilis, only to have the PHS exempt them. Pleased at their success, the PHS representative announced: “So far, we are keeping the known positive patients from getting treatment.” The experiment continued in spite of the Henderson Act (1943), a public health law requiring testing and treatment for venereal disease, and in spite of the World Health Organization's Declaration of Helsinki (1964), which specified that “informed consent” was needed for experiments involving human beings. Blowing the Whistle The story finally broke in the Washington Star on July 25, 1972, in an article by Jean Heller of the Associated Press. Her source was Peter Buxtun, a former PHS venereal disease interviewer and one of the few whistle blowers over the years. The PHS, however, remained unrepentant, claiming the men had been “volunteers” and “were always happy to see the doctors,” and an Alabama state health officer who had been involved claimed “somebody is trying to make a mountain out of a molehill.”

The PHS did not accept the media's comparison of Tuskegee with the experiments performed by Nazi doctors on Jewish victims during World War II. Yet the PHS offered the same defense offered at the Nuremberg trials — they were just carrying out orders.

Under the glare of publicity, the government ended their experiment, and for the first time provided the men with effective medical treatment for syphilis. Fred Gray, a lawyer who had previously defended Rosa Parks and Martin Luther King, filed a class action suit that provided a $10 million out-of-court settlement for the men and their families. Gray, however, named only whites and white organizations as defendants in the suit, portraying Tuskegee as a black and white case when it was in fact more complex than that—black doctors and institutions had been involved from beginning to end. The PHS did not accept the media's comparison of Tuskegee with the appalling experiments performed by Nazi doctors on their Jewish victims during World War II. Yet in addition to the

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The Tuskegee Syphilis Experiment

medical and racist parallels, the PHS offered the same morally bankrupt defense offered at the Nuremberg trials: they claimed they were just carrying out orders, mere cogs in the wheel of the PHS bureaucracy, exempt from personal responsibility. The study's other justification—for the greater good of science—is equally spurious. Scientific protocol had been shoddy from the start. Since the men had in fact received some medication for syphilis in the beginning of the study, however inadequate, it thereby corrupted the outcome of a study of “untreated syphilis.” The Legacy of Tuskegee In 1990, a survey found that 10 percent of African Americans believed that the U.S. government created AIDS as a plot to exterminate blacks, and another 20 percent could not rule out the possibility that this might be true. As preposterous and paranoid as this may sound, at one time the Tuskegee experiment must have seemed equally farfetched. Who could imagine the government, all the way up to the Surgeon General of the United States, deliberately allowing a group of its citizens to die from a terrible disease for the sake of an illconceived experiment? In light of this and many other shameful episodes in our history, African Americans' widespread mistrust of the government and white society in general should not be a surprise to anyone. 1. All quotations in the article are from Bad Blood: The Tuskegee Syphilis Experiment, James H. Jones, expanded edition (New York: Free Press, 1993).

Related Links: Black History Month Features U.S. Public Health Service Tuskegee National Historic Site Tuskegee University (formerly the Tuskegee Institute) Internet Resources on the Tuskegee Study Clinton's Apology for the Experiment

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