The handling of the corona epidemic in the Netherlands was clearly ageist. The disproportionate investments made in hospital care were meant to safeguard youngsters whereas care of older people was neglected. Their autonomy and a self-chosen end of life was stifled and frail older people were shut off from the outside world.
When at the beginning of 2020 corona appeared on the scene, government leaders, politicians, medical doctors, and scientists resolutely decided to lock down society and close the national borders to stall the epidemic. This collective, intuitive response – to which there were worldwide few exceptions – contained the epidemic and helped to prevent the health care systems from collapse. In almost all cases, a so-called ‘black scenario’ has been averted and a large number of deaths have been prevented. This makes the lockdown an extremely effective public intervention, but the simultaneous (in)tangible costs of the social hygiene measures are unprecedentedly high and make it difficult to continue a lockdown for long.
Ageism is the stereotyping and discrimination of individuals or groups solely on the basis of age. Ageism is different from other ‘isms’ as we are both perpetrators as well as victims of ageism during our life course. This is the first of three blog posts in a mini-series on ageism based on professor Rudi Westendorp’s thesis “Who Says I’m Old? A psychodynamic take on age discrimination” which completed his Executive Master in Change program at INSEAD in 2021. Get the full theses with references here
Remarkably, this initial success has not led to a deeper, fundamental reflection on how to best handle the corona epidemic. The scenario of a shorter or less strict lockdown with the risk that there is not always a place available at the intensive care, a horrifying thought for those who suffer death anxiety, should have been considered as society has set clear limits on what a gained year of life is allowed to cost. This utility logic is the foundation for the supply, access and sustainability of national healthcare systems. In case of corona it is gradually becoming clear to all that the existing boundaries of what a life-year may cost are being exceeded by far. The displacement costs are visible in the form of, among others, delayed and postponed regular care, accumulated educational disadvantage of youngsters, psychological and physical deterioration of many, and incremental economic costs for all. There is a generalised unwillingness to do the utility calculations. The few serious attempts that have been made are simply neglected, doubted and or ridiculed, apparently as a social defence mechanism.
An illuminating insight may have come from understanding our emotion that we cannot bear to see patients dying from corona without us trying to save their lives in the temples of medicine. Suppose that intensive care treatment for corona would not be useful, would we have gone into lockdown that strict for so long? It is significant that annual excess mortality among older people due to influenza goes virtually unnoticed.
During the winter of 2018, only in the Netherlands 10,000 people died of influenza, an excess mortality that is comparable in number and age distribution to the ‘first wave’ of corona, but at the time this excess mortality did not lead to collective action.Rudi Westendorp
It is not that social hygiene measures would not be effective to prevent influenza. The lockdown was so effective that during the 2020 winter season in the Netherlands, as in many other countries, not a single case of influenza was detected. Neither has 2018 seen a massive public response to increase the vaccination coverage of health professionals and the general population. Finally, there was also no sign of an ‘entrepreneurial spirit’ to develop a more effective vaccine against influenza, although the mRNA techniques for making a ‘new generation’ of vaccines was already available at that time.
Disproportionate investments – to save youngsters
It is conceivable that the collective (un)consciously looking away from excess mortality during earlier influenza epidemics can be explained by the fact that death from influenza almost exclusively concerns older people of whom the economic value is limited. This sentiment also seems to play out when at the start of the corona epidemic disproportionate investments are made in hospital care, also meant to save youngsters, at the expense of investment in long-term (institutional) care where the epidemic is razing among (frail) older people. This prioritisation made that corona hit unprecedentedly hard among clients of long-term care, and their healthcare workers in terms of mortality, trust and emotional burden.
This alarming age discrimination provoked a secondary, intuitive but irrational response. Faced with the facts, a guilt-ridden parliament in the Netherlands argued that age should not be used for triaging of who should be granted or denied admission to the intensive care. It is a fact that calendar age best predicts the outcome of medical intervention. The idea that all older patients should be treated at the intensive care protected politicians from being blamed of age discrimination but the reasoning is simply wrong and undesirable. Many older patients knew better and had decided themselves, or together with their attending physician, to forego nihilistic intensive care treatment and instead decided to invest in a more dignified end of life. The fact that in the Netherlands many older people have taken control of their own lives has significantly contributed that ‘a-run-on-the- ICs’ has been averted and the health care system has not collapsed.
It’s sad what has happened. Initially, care-dependent older people at home and (terminal) patients in nursing homes have been left alone to fend for themselves, but when the corona epidemic progressed, (frail) older people were no longer allowed to die from corona and finally it was decided that they would be the first to be vaccinated against the virus. In the meantime, (institutionalised) older people were shut off from the outside world, as they were no longer allowed to see their loved ones and were deprived of a dignified death. Youngsters in power one-sidedly prioritised the length of life of older people above its quality.
The plea for autonomy, self-determination and a self-chosen end of life was stifled. Many older people at home or in a nursing home have mentioned that ‘such an enforced isolation should never happen again’.Rudi Westendorp
The corona pandemic mercilessly shows the need for more rational choices to tackle the epidemic and advance the outcome and autonomy of (older) individuals. It should be prevented that social organisations or ideologic movements have a disproportionate influence on the collective response. The current corona policy in the Netherlands, as in most other countries, has a scientific basis but is also driven by fear of (one’s own) death, of those who have (the economic) power, and of subgroups who effectively influence public opinion (for their own sake).
What’s a life worth – from different viewpoints
Ask parents what their children’s lives are worth to them when they would suddenly become ill and die. Many of them would choose to turn this fate around when they were able to so. The evolutionary urge of parents to invest all for their offspring has no limitations.
Ask children what their parents’ lives are worth to them when they develop a fatal illness. Many would choose to push for another surgery, or medical intervention just to keep them alive for longer. The prospect of a final goodbye is often an impregnable barrier for children to let go of their parents.
Ask economists what a human life is worth. Their answer is that the value of a human life increases rapidly after birth and has a maximum at approximately 25 years because at that time the largest (in)tangible investments have been made. Thereafter, economic value remains stable until age 40 to 50, whereafter it rapidly decreases because investments in learning are stalled, health maintenance costs increase and economic productivity decreases with increasing age.
Ask society what a human life is worth. There is a widely shared view that there should be limits to the cost of medical treatment because the unbridled growth of health care comes at the expense of other social responsibilities such as education, business and the environment. The Council for Public Health and Care (RVZ) has formulated a limit of 80 thousand Euros per life year gained of good quality, the UK National Institute for Health and Care Excellence (NICE) uses a limit of 20- 30 thousand GPD.
Ask politicians what the life of their inhabitants is worth. Almost all would choose to put their own country first before worrying about neighbouring countries. The socio-cultural ideology of putting one’s own people first is dominant.
Ask a person what his/her own life is worth to her/him and there is no unequivocal answer. All people make an individual but different assessment of their own life lived, future expectations, and the willingness to make the necessary (im)material investments. This personal assessment is situation-specific and can fluctuate greatly over the course of life.