Sick children deserve optimal medical care. So why were my colleagues and I saddened by a California midterm ballot initiative aimed at doing just that?
Like the majority of Californians, I voted for the initiative to authorize $1.5 billion in bonds in grants for the “construction, expansion, renovation, and equipping of qualifying children’s hospitals.” Voting “yes” was the socially responsible, compassionate choice. My chagrin came not from what the measure will do for our state but from what is missing in health care funding — not just in California, but across the nation.
Given the vast number of children who have died throughout most of human history (in 1900, 30 percent of all deaths in the United States occurred in children less than 5 years of age), we are fortunate to live at a time when most children are healthy and live into adulthood and beyond. While children and adolescents make up 23 percent of the U.S. population, they account for only 16 percent of hospitalizations, mostly in the first year of life. If you exclude infants, individuals under age 18 make up just 4 percent of hospitalizations.
Thanks to 20th-century advances in public health and medicine, a majority of Americans now live into elderhood. More children today benefit from education bonds than health care bonds. Yet our policies and priorities are still directed at century-old needs and demographics.
In the 21st century, health care is to elderhood as education is to childhood. But we don’t see bond measures for the “construction, expansion, renovation, and equipping” of hospitals to optimize care of old people, an investment that would surely benefit Americans of all ages.
People age 65 and older make up just 16 percent of the U.S. population but nearly 40 percent of hospitalized adults. In 2014, Americans over age 74 had the highest rate of hospital stays, followed by those in their late 60s and early 70s.
Remarkably, hospitals aren’t designed with elders in mind. Walk through one and you’ll almost invariably find cheerful decor for children, services and facilities aimed at adults, and a gauntlet of obstacles and insults to elders.
At most hospitals and medical centers, the newest buildings focus on cancer, neuroscience, children, and research. Old people end up in old buildings. That usually means long walks down halls without railings or chairs with arms for rest stops. It means signs that are hard to read until you are right under them. It means a one-size-fits-all approach to both facilities and care that doesn’t acknowledge that the needs, preferences, and realities of a 75- or 95-year-old with a medical condition might differ from those of a 35- or 55-year-old with the same thing.
It’s the rare industry that doesn’t target and cater to its best customers. Health care not only fails to cater to elders, it fosters system-wide injustice by failing to apply the same standards to elderhood that it applies to childhood and adulthood. Just as children’s hospitals have been shown to save and better the lives of children, hospital wards, services, and emergency departments aimed at elders improve their care and lives when compared to adult-centric facilities.
The good news is that we already know what to do to make hospitals safer and more welcoming to older patients and family visitors.
A collaboration of industry leaders, including the American Hospital Association, the John A. Hartford Foundation, and the Institute for Healthcare Improvement, has launched an age-friendly health system initiative. While its purview is limited to a few geriatric conditions, it’s a step in the right direction. (And the field of geriatrics is finally beginning to model itself after pediatrics, taking a more whole health, life stage approach to elderhood.)
Some of the best ideas for hospital design come from outside health care. Innovations developed for aging-in-place homes or continuing care communities offer prototypes of “silver architecture.” Businesses like Microsoft are investing in structural and people-flow design that meets needs across the lifespan. They are adopting the position that if you design for the mythical “average human” you create barriers, whereas if you design for those with disabilities you create systems that benefit everyone.
Hospitals will find that many features that would benefit their older patients already exist in their newest facilities. Useful tech-based design elements include communication options that don’t require finding and pressing a call button, as well smart monitors that identify staff members on a large TV as they come into the room. While such technology helps all patients, it’s particularly beneficial for people with impaired vision, hearing, dexterity, or thinking.
Rooms in many new children’s hospitals are equipped with a pullout couch bed and privacy screens. Such accommodations are just as important for the children of old patients as they are for the parents of young ones. Any adult child of a sick elder parent can tell you bad things happen when they aren’t present to watch over their loved one. My father was cared for at my top 10 medical center, and my mother is being care for there now. I wouldn’t have them go anywhere else and yet, after 20 years as a geriatrician, I would never leave them there without one of us staying with them for protection.
Arguments for spending billions of dollars on children’s hospitals often emphasize that saving a child offers the best return on our societal investment. In terms of potential years gained, that may be true. But valuing some lives over others teeters on a logic disturbingly reminiscent of past measures that ensured the marginalization, institutionalization, and deficient care of people because they were disabled, poor, brown-skinned, black-skinned, or female. Hospital design and health care should not penalize us in elderhood for having benefited from medical care in childhood and adulthood.
There is also this immutable fact: Although some of us will develop cancer or AIDS or other diseases, most of us will become old. Denying that basic truth ensures that we will have the elderhood we fear, the one our society and medical system too often dismiss and deride.
Anyone not planning on dying prematurely should consider doing the following: When supporting an adult or children’s hospital, ask what it is doing for elders, the “third age” of life. When voting for a ballot measure aimed at the “construction, expansion, renovation, and equipping” of hospitals, make sure that it covers the people most likely to require hospital care.
Youth, absolute or relative, should not be a prerequisite for modern facilities, compassion, and good health care.
Louise Aronson, M.D., is professor of geriatrics at the University of California, San Francisco, and director of the UCSF Health Humanities and Social Advocacy Initiative.