Ageism and the mythos of sacrifice during the COVID-19 pandemic

1 Department of Psychiatry, National Institute of Mental Health and Neurosciences

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Author of Correspondence: Migita D’cruz, Senior Resident, Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences. Bangalore 560 029, Karnataka, India. Email: migitadcruz@gmail.com

The WHO defines ageism as the stereotyping, prejudice, and discrimination against people on the basis of their age. It further goes on to note that ageism is widespread and an insidious practice which has harmful effects on the health of older adults. [1]

While the mental images that this description conjures is of overt abuse and neglect, ageism is often far more subtle and insidious. It extends from structural exclusion (lack of age friendly toilets in public spaces) and micro-aggressions (references such as “these old people”) to hate events (violence). [2]

In this context, even positivist outlooks on ageing often subscribe to ageist stereotypes. In psychoanalytic theory, Erik Erikson’s eighth psychosocial stage of ego integrity versus despair and Carl Gustav Jung’s archetype of the wise old man (the sophos or senex) and the wise old woman (the crone) conceptualize purpose in older age as a process of giving or sacrifice. [3][4]The healthy older adult is often conceptualized as a being devoid of desire and ambition, who has attained mastery of crisis and a higher level of spiritual development. Their role in the family, the community and in society is as a keeper of knowledge and a guide, who, when called upon, will lay down their life for the greater good – the mythos of sacrifice. The Indian cultural representations of this transcendence include the Saptarishi and the Navaratnas.

We are in the first year of the WHO decade of healthy ageing (2020-2030), aligned to the UN Agenda for Sustainable Development 2030. [5][6] Ironically enough, we are fraught, managing a pandemic that seems to have brought out the ageism innate to health care. Older adults have been recognized, from epidemiological data, to be at disproportionately higher risk of contracting a severe infection, multi-organ dysfunction, disability and mortality from the

novel coronavirus infection. [7][8] However, the recognition of these risks to older adults in the context of the pandemic appears to have brought out a disparate set of responses in society. Common to many of these responses to the pandemic, appears to be a basis in ageist myths and stereotypes. These include:

  1. Structural Exclusion: The public health guidelines issued by the WHO, CDC and Ministry of Health and Family Welfare emphasize shelter in place, physical distancing and the reverse quarantine of older adults to mitigate the risk of their exposure to COVID-19. While these directives are undoubtedly crucial for physical health, the impact upon the mental health and well-being of older adults – a population already vulnerable to loneliness and social isolation prior to the onset of the pandemic – remains largely unaddressed.[9] Older adults who contravene the curfew – often to seek essentials such as food and medicines have reported harassment and abuse by neighbours and law enforcement to the Elder Helpline run by the Geriatric Clinic and Services at NIMHANS.
  2. Cessation of non-essential services: Older adults are among the highest consumers of non-essential health related services. These include, but are not restricted to – dental care, physical therapy, visual aids, auditory aids, neuro-psychological services (including psychotherapy and cognitive retraining), community health care, social services, pain management and palliative care. The implication is that these services can be halted in order to ensure physical distancing and to relocate resources to other, more essential services during the pandemic. [10] The long term cost of these administrative decisions may be considerable – with deterioration in the quality of life and increase in morbidity and disability in older adults due to impeded access to health care. It is expected that this increase in the global burden of disease in older adults will persist long after he world emerges from the pandemic. [11]
  3. Prioritization of intensive care: Conventional triage in intensive care units often means that ventilators and other intensive care facilities are reserved for those most likely to benefit from these resources. Physicians in Italy have reported having had to make difficult decisions such as sending those infected above 80 years of age home while allocating scare health care resources. [12] Older adults are thus, due to factors such as a propensity to frailty and multi- morbidity, lower in priority than young and middle aged adults in health care.
  4. A call to older adults to sacrifice themselves: The Secretary General of the United Nations – Antonio Guterres launched a policy initiative to address challenges faced by older adults during the coronavirus pandemic and called for respect for their rights and dignity. [13]Against the backdrop of this call –the lieutenant governor of Texas has called for people to return to work and suggested that older adults be willing to sacrifice themselves for the nation and the economy. A journalist at The Telegraph has postulated that the pandemic could prove beneficial to the economy by culling the elderly. [14] Economists in India have suggested the lockdown may be an excessive response to the pandemic in a young demographic such as ours with lower risks of mortality – despite the absolute number of older adults in india being estimated at 108 million in a National Report on Elderly in India in 2016 – a not inconsiderable number. [15,16] #BoomerRemoval has been seen to trend on social media. [14] Apart from being in poor taste and indicative of eugenic intent – the overt endorsement of ageist sentiment by public figures and heads of state serves to normalize the devaluation of older adults and convey the perception that hate speech is acceptable in times of crisis.
  1. Infringement upon autonomy and decision making: The global and national response to the pandemic has also included the curtailment of civil liberties and autonomy in the general population. Again, while this is undoubtedly important to the containment of infection – older adults, alongside other vulnerable population groups are disproportionately affected by the infringement upon their autonomy. This has interacted with the increased risk of COVID-19 infection in older adults to take decisions about their place of residence, treatment, social mobility, bodily integrity and interment out of their hands. [17]

Several of these factors are non-specific to older adults and the Indian context; many of them have existed long before the COVID-19 pandemic and will, likely, outlast it. The sub-text of stigma and exclusion is often common to other forms of discrimination, including but not limited to sexism, casteism, xenophobia, theophobia and nativism. [17]

What is novel, however, to the impact of the pandemic upon older adults is the mythos of sacrifice. [18] Older adults have completed their life tasks and their designated number of years around the sun. They are thus believed to best serve society, by not demanding their rights and services that are their due, by staying away from the over-burdened health care system and not seeking care even if ill. Thus, in the context of the pandemic, not only has covert ageist discourse become overt, but it has also acquired moral and altruistic overtones. Older adults have not just been marginalized – such would have bad enough. They are also expected to willingly embrace and participate in their own marginalization, internalizing

ageism. In this duality of recognizing older adults as venerable and expendable – we come close to the Jungian shadow. [4]

Age and the human rights agenda:

Article 1 of the Universal Declaration of Human Rights states – all human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. Article 7 states – all are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.[19]

Similarly, article 14 of the Indian Constitution states – the State shall not deny to any person equality before the law or the equal protection of the laws within the territory of India. [20]

The fundamental rights incorporated by these documents are intended to preclude discrimination, including ageism. These rights are more important than ever before in a health care crisis such as the pandemic. [21]

The way forward:

As the world prepares to live with the novel coronavirus pandemic and to plan for a post pandemic future, the health care agenda should be inclusive of older adults. They must be incorporated in planning and decision making rather than be the beneficiaries of altruistic paternalism. Further, a case can be made for individualized care for older adults – respectful of diversity and based upon stochastic age(a more accurate predictor of health risk) rather than chronological age. Their role in the community must reflect their sense of self and motivations and desires, rather than to be the other in the dynamic narrative. [21]

References

  1. Ageism [Internet]. World Health Organization; [cited 2020 May 6]. Available from: http://www.who.int/ageing/ageism/en/
  2. Cohen ES. The Complex Nature of Ageism. What Is It? Who Does It? Who Perceives It? Gerontologist [Internet]. 2001 Oct 1 [cited 2020 May 9]; 41(5):576–7. Available from: https://academic.oup.com/gerontologist/article/41/5/576/596571
  3. Erikson EH, Erikson JM, Kivnick H Q. Vital Involvement in Old Age [Internet]. 1989 [cited 2020 Apr 4]. W W Norton & Co. Available from: https://psycnet.apa.org/record/1986- 98498-000
  4. Jung CG. Collected Works Of C.G. Jung [Internet]. 1953 [cited 2020 May 24]. Princeton: Princeton University Press. Available from: https://press.princeton.edu/books/ebook/9781400851065/the-collected-works-of-cg-jung
  5. Lloyd-Sherlock P, Kalache A, Kirkwood T, McKee M, Prince M. WHO’s proposal for a decade of healthy ageing. The Lancet [Internet]. 2019 Dec 14 [cited 2020 May 9]; 394(10215):2152–3. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32522-X/fulltext
  6. Global strategy and action plan on ageing and health [Internet]. World Health Organization. 2017 [cited 2020 May 10]. Available from: https://www.who.int/ageing/WHO- GSAP-2017.pdf?ua=1
  7. Adhikari SP, Meng S, Wu Y-J, Mao Y-P, Ye R-X, Wang Q-Z, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infectious Diseases of Poverty [Internet]. 2020 Mar 1727 [cited 2020 May 9]; 9(1):29. Available from: https://idpjournal.biomedcentral.com/articles/10.1186/s40249-020-00646-x
  1. WHO delivers advice and support for older people during COVID-19 [Internet].World Health Organization; 2020 Apr 3[cited 2020 May 9]. Available from: https://www.who.int/news-room/feature-stories/detail/who-delivers-advice-and-support-for- older-people-during-covid-19
  2. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health [Internet]. 2020 Mar 20 [cited 2020 May 9]; 5(5):e256. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104160/
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