Growing Old in America
In December of last year, my grandmother, a survivor of Auschwitz, one of the last of her generation, died in her bedroom at the age of 97. Her decline came swiftly — one day she was ambulatory, fragile and aged, but still fierce and independent; the next, she was partially paralyzed and confined to a bed.
Unlike the majority of Americans, I grew up in a multigenerational household. As a result, I was present for the evening of my grandmother's life, from the time I was born to her death last winter. When she was able-bodied and relatively healthy, her part-time caretakers, my mother especially, supported her emotionally and socially. After her stroke, which consigned her to a bed for the last months of her life, these same young caretakers became not only her friendly company, but her diligent nurses who took on the difficult, often grueling and emotionally taxing work of tending to someone who can no longer take care of herself.
Being present for my grandmother's final decades, during which her loneliness was as clear as any physical infirmity, made me consider how I might want to age. Watching her grow old made me wonder how I would face aging — how I would deal with its challenges, whether I would face them with courage or buckle beneath their weight. I thought about how humiliating it might be to have people hired to spend time with me. Though my grandmother's mind had clearly declined, she wasn't oblivious — she knew what these caring, gentle, devoted young women were doing for her. She would say as much, and tell me she never thought it would have to be done for her. We rarely do, but now I know better.
As a young man, I witnessed a woman I loved deeply, almost as a second mother, progress through the most difficult stages of life. Through it all, I caught a glimpse of what the future might require, the challenges it might present, and the preparations we should, or must, make as a society for the demographic shift to come.
AN AGING WORLD
Today, Americans aged 65 years and older make up an estimated 17% of the American population, numbering about 55 million people. Of this population, the median age is 73, meaning that more than 27 million Americans are 73 years of age or older. In 2010, the percentage of Americans 65 and older was just 13%, or 40 million. This means the senior-citizen population grew by a staggering 40% between the two decennial censuses.
The increase is more shocking still when one considers that the U.S. population as a whole rose by only 7% during that decade. If we widen our temporal lens, we discover that America's elderly population in 1970 was 10% of the total population, or 20 million individuals. In the half-century since, the total population has grown from 203 million to 331 million — an increase of 63%. In the same period, the elderly population swelled by 175%.
Given our graying population, one might suspect that figuring out ways to best care for older Americans would dominate the national conversation. But within the small circle of elite commentators who drive that conversation, the collapsing birth rate in America and the West more broadly has garnered far more interest. This is an important challenge, of course: Falling birth rates mean a nation's population will shrink, which diminishes the labor force, strains pension systems, and puts demographic sustainability at risk. And yet the flip side of this trend — the explosion in the senior-citizen population — poses its own problems.
When commentators do discuss the elderly, they often focus on the root causes of the demographic transition to an older population, or the effect this transition will have on economic growth. Far less attention has been paid to what it might be like to grow old in this world. The question is pressing because, barring an unprecedented baby boom or population collapse, this aging society is our future.
Our improved ability to manage chronic conditions through medical advances, combined with our lengthening life spans, has made long-term caregiving a more urgent concern than attending to acutely ill patients. And the peculiar demographic trends of our age — longer life spans and fewer children — complicate traditional patterns of caregiving among families. Caring for a larger elderly population with fewer caregivers leaves us with practical and ethical dilemmas that we have only begun to contemplate.
Though our era presents unique difficulties, caring for the elderly or otherwise infirm was always a feature of human sociality. By considering the history of our response and that of other countries to this enduring predicament, we can begin to think through how we might address it now and in the future.
THE AMERICAN WAY OF CARE
Americans have typically turned to relatives to care for the elderly — a role traditionally filled by women. These caretakers had no specialized training or credentials; they were simply expected to shoulder the burden. They became experts in their own ways, developing a system of embedded knowledge and experience passed down from mother to daughter across the generations.
In such times, large families and kin networks helped distribute the burdens of caregiving among female relatives more evenly. Yet their work was often made more difficult by the lack of certain luxuries that have made modern caregiving and other domestic responsibilities easier: While a caretaker today can turn up the thermostat to increase the heat or put a load of laundry into a washing machine, women of the past had to keep a fire going or spend most of the day washing soiled bedsheets. These were not simple chores. After an exhausting day of caring for a sick or elderly relative, a woman in the distant past would return home only to confront her other household obligations.
Matters began to change somewhat during the 19th century. The vertiginous increase in America's immigrant population, coupled with countrywide urbanization, produced U.S. cities that were crowded, filthy, and unequal. The tenement cities of the Northeast became the defining picture of American immigrant life.
While the coronavirus pandemic reminded us of something that was, until very recently, an enduring feature of the human condition, we can scarcely imagine the difficulties caused by the presence of disease in the urban environments of the 1800s. Communicable diseases, especially waterborne bacterial infections, were an ever-present danger. Physical hygiene was a matter of life and death, and those who cared for the sick — in a time before the widespread understanding of germ theory, and before sewer systems and other public-health projects dramatically reduced the prevalence of disease — risked contracting typhoid, cholera, and tuberculosis on a daily basis. During the major cholera outbreak of 1849 in New York City, 5,000 people died — 1% of the city's population. The earlier outbreak in 1832, the worst in the city's history, killed 3,500 when the city's population was only 250,000.
That century, urbanization had a similarly profound effect on England and its culture. Contemporaneous accounts note both the promise and the penury of British cities as the wheel of industrialization turned. Florence Nightingale, the British nurse and social reformer, recognized the potentially miraculous benefits of visiting nurses for the sick poor in rapidly urbanizing England: "To set these poor sick people going again with a sound and clean house, as well as with a sound body and mind, is as great a benefit as we can give them — worth acres of gifts and relief."
On the other side of the Atlantic, Nightingale's model arose as a potential cure for the physical ailments that attend disease, accident, and old age. In No Place Like Home, the definitive history of visiting nursing in America, Karen Buhler-Wilkerson tells of how newly formed and scientifically minded nursing associations began to espouse the principles of germ theory, how "physical and moral hygiene" were linked, and how the "delicate instructions and firm convictions" of trained nurses "'bridg[ed] the gulf which lies between the classes and masses.'"
The visiting nurses who cared for patients in their homes, Buhler-Wilkerson writes in her 1989 book, False Dawn, worked hard to alleviate the "distressing symptoms" of their charges:
[G]lycerin for parched lips, cold compresses or ice bags for headache....Fever patients were treated with a "temperature bath" and a cool atmosphere was created by pouring cold water on the floor or by hanging sheets wrung out in ice water around the room....Patients with bronchitis pneumonia...had their chests rubbed with camphorated oil....Rheumatic joints were bandaged and children with measles bathed in saleratus water.
From its inception in America, visiting nursing began not only as a potential cure for the physical ailments that attend disease, sickness, accident, and age, but also for the spiritual and moral needs of the growing urban underclass. Buhler-Wilkerson tells the story of Mrs. John Lowman, a woman whose husband sat on the board of trustees for the Visiting Nurse Association of Cleveland at the turn of the 19th century. During the winter of 1902, Lowman joined one of the association's nurses on her rounds. She recalled the "situation" in the first home as dreadful: "I sat in a rocking chair, feeling very low in spirit and quite benumbed by astonishment and a kind of terror." Her nurse guide, however, was unfazed:
[T]he nurse, who was young, attractive, neat, and dainty in appearance, seemed to Mrs. Lowman quite at home....The nurse attacked the situation with cheerfulness and decision, rapidly setting the sick room and sick patient in order, changing the bed, washing the patient and combing her hair, and reordering the room for proper ventilation and light....[T]he "gossipy old woman"...was replaced by a "sensible looking" one who promised to carry out the nurse's instruction....[T]he nurse seemed entirely competent to handle these terrible situations and proceeded on her way to visit the six or seven patients remaining on her list.
Though I was separated from her by more than a century, I knew the nurse Mrs. Lowman described. She was like my grandmother's own caretakers who, when confronted with difficult conditions (though admittedly much better than those of an early 20th-century urban tenement), got on with their duties with an optimism and grace that one cannot help but admire. They did beautiful work, even when the work was less than beautiful — changing my grandmother's diaper, cleaning her, stroking her face, talking to her like they had all the time in the world. These women were composites of loving courage, strong-willed and confident. They served not only a medical, but a civilizing purpose in their work, restoring and maintaining my grandmother's dignity in her later years.
It is not surprising that nursing took on these dual functions. Holistic care — not just of body, but of environment, routine, and mind — is essential. Even in our sanitized world, where disease and filth have largely been relegated to the periphery, and where digital media often substitute for social relations, caring for the ill, the disabled, and the elderly remains profoundly intimate.
CAREGIVING TODAY
The stereotypical assumption is that most 21st-century Americans can't be bothered to care for their elderly relatives, preferring instead to send them to nursing homes or other facilities. The evidence doesn't quite bear this out, however: The percentage of Americans 85 and older residing in nursing homes and other group settings, such as assisted-living facilities, declined from 24% in 1990 to 11% in 2014.
In fact, professional nursing was never the way most Americans received care. Today, adult women — often daughters — bear most of the burden of caring for their aging parents. The stresses and hardships they face — emotional, financial, physical, and spiritual — are significant. Their own spouses and children suffer from their lack of availability. These hardships have only grown more acute as the demographic transition takes shape: Due to the declining birth rate and longer life spans, fewer daughters must now care for their older parents for longer periods.
One way families are coping with increased caregiving responsibilities is by arranging for their elderly parents to move in with them. The number of Americans living in multigenerational homes — defined as three generations living in one home — has increased since the 1970s; 18% of Americans lived in multigenerational households in 2021, compared to 7% in 1971. Most of these Americans do not mention caregiving for an adult as the reason for moving into a multigenerational home: When surveyed by the Pew Research Center, only 45% mentioned adult care as a major or minor reason for the formation of their multigenerational home. But responses varied by income — the poorer the respondent's family, the more likely he was to say that giving or receiving care was a reason for a given living arrangement. And of course, families that form a multigenerational household for reasons other than caretaking may find themselves assuming such responsibilities for older members of the household over time.
THE ECONOMICS OF CAREGIVING
As we have seen, caregiving is a personal and social endeavor often provided by family, friends, and charities. It is difficult work with enormous emotional and moral costs. It is also particularly labor intensive: Those providing care are not easily substituted by technologies or other forms of capital. Thus, our aging society will face intense pressures in the coming years, the most challenging being a shortage of caregivers to look after the elderly during one of the most vulnerable and lonely periods of their lives.
Economic theory teaches that a labor shortage is a supply-and-demand problem — the demand for workers outstrips the supply a society can provide. Companies can respond to this shortage on the supply side by raising wages, bringing more people into the labor force, or poaching workers from other sectors and industries; or they can focus on the demand side, by reducing production and accepting slower growth. They can also, under the right conditions, substitute new technology for higher labor costs — by replacing retail workers with self-checkout kiosks, for example. If the political climate allows, companies can find more workers through immigration or offshoring.
But the American public has become increasingly skeptical of increased immigration, and a nursing home can't offshore its operations. In tasks like nursing or caretaking, where the social interaction between caregiver and cared-for is paramount, it is difficult to replace the human touch. Few of us, when asked what kind of care we would like for ourselves, would say we want "efficient" or "productive" care.
Institutional caregivers and nursing facilities seeking to maintain operations in our aging society face a difficult choice: They can either reduce quality — which is not desirable — or raise wages, leading to escalating costs that are passed on to patients, insurance companies, and the state. And while these higher wages will certainly attract better and more capable workers and incentivize good work, the increases in productivity are not commensurate with the increase in wages, which are driven by forces in the economy as a whole rather than industry-specific productivity gains. This is known as Baumol's cost disease — upward pressure on wages economy-wide that leads industries that depend more on labor than capital to raise labor costs without necessarily generating an increase in the quality of the service provided. To the consumer, the cost of care will seem to be spiraling upward. And even if quality of care increases, many will be priced out of it.
Thus, when labor costs rise, the stresses on nursing homes, hospitals, hospice, and home-health aides are more acutely felt than in other industries: A barista is more easily replaced by a machine than a nursing-home aide. Furthermore, if an adult daughter is providing intensive care for her parents or husband, the wages she will forgo (what economists call her "opportunity cost") will be much more valuable — a greater sacrifice in a labor-scarce economy. As Robert Saldin has noted in these pages, working- and middle-class families in particular are squeezed by this situation: They are not poor enough to qualify for Medicaid, and Medicare does not cover the cost of long-term care for their elderly family members.
The future of caregiving in America will be shaped by these forces. The sector will face extreme pressures to find ways to substitute capital for labor — and some solutions will be less pleasant than others.
ETHICAL QUANDARIES
The burden of caring for the elderly was always difficult for human society. But as we have seen, America's demographic transition will focus and intensify these responsibilities. Most of them will fall on the immediate family members and friends of the people requiring care. In smaller families, spouses especially will find themselves isolated and faced with incredibly difficult choices.
Consider the many heartbreaking stories Emily Abel tells in her book Elder Care in Crisis. Drawing from the public posts on group forums of spouses caring for their declining husbands and wives, Abel paints a picture of increasing desperation. Many of the spouses she includes in her book had been caring for their loved one for years and avoided bringing in outside help. Others made the agonizing decision to place a husband or wife in "adult day care" settings, or assisted living or nursing facilities.
In a world with smaller kin networks and disconnected communities, the contours of our relationships — of what marriage might become when the burdens of care grow too great, for example — can change radically and surprisingly. And in our graying society, where the costs of personal care may be prohibitive, we will increasingly come to rely on technological substitutes for human care. But not all substitutes are created equal.
Imagine a digital assistant, much like Amazon's Alexa or Apple's Siri, but with more convincing vocalization enabled by artificial intelligence. Chat bots like ChatGPT have already demonstrated how easily a language model can simulate human thought; these same language models could soon be used as a source for the digital assistant's vocalization — a passable simulacrum of human connection. Would enlisting these assistants to keep Alzheimer's patients company throughout the day — relieving the considerable burden on their stressed caregivers — be an ethical way to substitute for scarce relatives and aides? My family and my grandmother's caretakers spent hours keeping her company. When the costs of such services rise considerably, is it not possible that desperate families might make use of these options?
It would certainly be convenient and cost-effective to do so, and when families are desperate, rules can be bent.
If the preceding account disturbs you, consider darker futures still. Younger adults these days are more than comfortable with spending long hours in front of screens — scrolling TikTok, playing video games, performing their day job. Our virtual worlds will only get more engaging and expressive and engrossing. Our virtual-reality technologies might still be clunky and uncomfortable, but they will only improve, and their use cases will expand. Our old-age homes could be filled with men and women captured by virtual worlds, giving them experiences strange and exciting — far more so than those available in their dull surroundings.
But there are other ways in which technology might assist us in a manner more consistent with our values. "Care bots" — increasingly common in Japan — can supplement human care by partially alleviating the physical burdens of caretaking. These robots perform distinct tasks that preserve the dignity of the cared-for while reducing the stresses on caretakers: lifting an immobile patient from his bed, for example, or assisting a tremorous Parkinson's patient with eating.
An aging society will also challenge our politics. Many caregivers today, whether working in formal institutional settings or in less formal household settings, are immigrants, or are drawn from immigrant communities. The economics and family structures of a graying population will increase demand for such caretakers. But Americans and Western publics more generally have turned against mass immigration. Conservatives may have to balance their political concerns about immigration with their belief in the inherent dignity of the dependent.
Accepting caretaker immigration as a formal process has its own difficulties. As kind as strangers can be, most of us would prefer to be taken care of by our own family members. Hired help, even of the most patient and generous kind, cannot easily substitute for the loving care of a son or daughter.
MORAL NONENTITIES
While aging in our time presents peculiar challenges, it was never easy. Getting older has always meant becoming lonelier. Parents, spouses, siblings, and friends all die. Children have families of their own. Yet given our aging population and the shrinking younger generations, loneliness is likely to be our primary struggle going forward.
Loneliness takes many forms. One familiar to those who have cared for elderly relatives is their infantilization, or exile from the "moral community." To be human is to be social; the unique features of the human species all heighten and accentuate our sociality. The breakdown of normal social relationships with a person is thus a kind of excommunication from the human species.
I felt this acutely when observing my grandmother's senescence. When she said something offensive or that lacked concern for our feelings, the inevitable refrain was that it was not her fault. It wasn't, of course. But that's also what we say of pets or small children. The fact that it was true did not make it less demeaning. Ethicist William May wrote perceptively that such excuses "may subtly remove [the elderly] from the human race" as "moral nonentities."
Another difference is that small children grow up. We excuse them in the moment, but we try to teach them well and correct their behavior because we know this moral, ethical, and social tutelage will one day help them become full, responsible members of our society. The same cannot be said for the old. There is no "tutelage" for the elderly — their infirmities are permanent and ever-growing. There is no improvement to be had, no preparation for joining society. We are instead preparing them to leave it forever, to usher them off the stage before strange actors take their place, to leave a world in which they are no longer needed.
This was the most difficult part of seeing my grandmother's decline. Almost all my conversations with her from a certain imperceptible point became palliative. I had a very close relationship with her; she was more like a second mother than a grandmother to me. We teased each other, argued, and laughed together. But as her mind began to wander away from her body — as the weight of her soul proved too heavy a burden for its material encasement, such that she could no longer be the person I once knew her to be — our conversations narrowed.
When the person you are speaking to will forget most of what you say, or misunderstand it, or ask the same question repeatedly 10 times or 100 times in the course of an afternoon, can you in all honesty dedicate yourself fully to each conversation as you might with another person? Or are you engaging with her only to make her happy — to make her comfortable? This is not a conversation — this is hospice by another name; this is you spending down your relationship with every lie and obfuscation, with every laugh at a joke you didn't quite understand. You would rarely talk to another person this way — and if you did, you might feel bad about it later. But with the elderly, you cannot help it; with a person's decline, the social bonds that once braced you to each other break down. The weight of your past relationship cannot be borne by these rusted tethers — you are already losing your loved one.
MOVING FORWARD
Our aging world will put increasing strain on our ability to live in dignity, and to provide for our loved ones the care they deserve. Impossible choices seem, at this point, inevitable. Younger people especially should start thinking now about how they want to age — to make preparations in the morning for the evening — for their own lives, but also for their parents. It might mean thinking seriously about their family patterns, their marriages, their careers, where they want to live, and how many children they want to have. It may also mean spending more time among the elderly and disabled — learning from them how to weather our future struggles. I know living with my grandmother helped me in this way — perhaps it may help you, too.
These are not simple challenges, and we would be wise to start thinking about potential solutions. It can be alluring to think of our problems as exceptional. Common problems invite common solutions, daring us to rise to the occasion; exceptional problems allow us to fail in the comfort that we did our best under the circumstances. But we are not so special — previous generations had their share of selfishness and deracination, of yearning and suffering, of chafing under obligations and bending beneath burdens.
And we will certainly bend to convenience, in small ways and large. We should be careful not to bless our momentary surrenders. Our techniques for dealing with an aging world are not path dependent, and not all of them accord with our ethical obligations. Better to think now what we would want for ourselves before we become too dependent to have a say in the matter.
